CHOLERA: 



ITS CAUSES, SYMPTOMS, PATHOLOGY AND 
TREATMENT. 



ROBERTS BARTHOLOW, M.D., LL.D., 

emeritus professor of materia medica, general therapeutics and 

hygiene in the jefferson medical college of philadelphia | 

fellow of the college of physicians of philadelphia ; 

member of the american philosophical society ; 

honorary member of the royal medical 

society of edinburgh, and of the 

soci£t£ m£dico-pratique de 

paris, etc., etc. 

author of a treatise on the practice of medicine, of a treatise 

on materia medica and therapeutics ; of a manual of 

hypodermatic medication ; of a manual of 

medical electricity, etc., etc. 




■ 

JUlv 20 \W 

PHILADELPHIA: $^ ft ' 

LEA BROTHERS & CO, 
1893, 






Entered according to the Act of Congress, in the year 1893, hy 

LEA BROTHERS & CO., 
In the Office of the Librarian of Congress. All rights reserved. 



PORNAN, rKINTEK, 



PREFACE 



An enforced idleness of several months, the con- 
valescent stage of a long and serious illness, I have 
employed in part in preparing this little volume at 
the suggestion of the Publishers. The literature of 
cholera is most voluminous, and the sources of in- 
formation are immediately available, so that it were 
a comparatively easy task to make a big book. I 
have sought to make a practical book in the smallest 
compass, and to that end I have utilized my personal 
experiences in two epidemics of this disease, and have 
avoided historical accounts of successive outbreaks, 
and disquisitions on disputed etiological points. No 
extent of individual observations can take the place 
of the multiplied experiences, the far-reaching dis- 
coveries, and the amazing fertility of resource of 
modern medicine, however, and hence I have in- 
corporated whatever is most noteworthy in the 
improvements made during the existing epidemic. 



IV PREFACE. 

The management of the present epidemic as com- 
pared with former ones manifests a distinct tendency 
toward germicide, or antiseptic remedies, and is 
characterized by the introduction and general use of 
expedients of a surgical kind — such as enteroclysis, 
intra-venous transfusion, hypodermatoclysis, and 
subcutaneous injection. Whether the results are as 
successful as the devices are ingenious, may admit 
of question in the light of the mortality statistics. 
Judged dispassionately and all deductions allowed, it 
must be admitted, I think, that some progress has 
been made, and although the uumber of deaths in 
some localities may be equal to those in former epi- 
demics, it yet appears certain that our therapeutical 
measures are attended with a constantly increasing 
improvement in the proportion of cures. Were it 
not so, I should hardly be justified in giving so 
much space, relatively, to the subject of the treat- 
ment of cholera as my readers will find that I 
have done. 

R. B. 

Philadelphia, May, 1893. 
1 527 Locust Street. 



CONTENTS 



CHAPTER I. 

PAGE 

Historical Introduction 13 

History ......... 14 

Epidemic of 1832 15 

Epidemic of 1848 15 

Epidemic of 1866 . . . . . .16 

Epidemic of 1892 16 

Cholera at New York 17 



CHAPTER II. 

Etiology or Causes of Cholera . . . .21 

Sanitary state of Mecca and Medina . . .22 

of Hamburg, Havre, Marseilles, and Paris 23 

Influence of climate 24 

of elevation ....... 25 

of sex 27 

of water-supply 29 

Cholera in Russia 31 

Koch's discovery of the spirillum of cholera . . 35 
Description of the bacillus 36 



CONTENTS. 

PAGE 

Its viability 39 

according to Ufl'elmann 89 

according to the German Imperial Board of 

Health 40 

Personal experiments of Fettenkofer, Emmerich, 

Hasserlik, and others 42 



CHAPTER III. 

The Symptoms of Cholera 
of the prodromal stage 
of systemic infection 
of the algid stage 
of the reaction, or typhoid stage 
Cholera sicca 



CHAPTER IV. 

Pathology and Morbid Anatomy 
Course, duration, and termination 
Mortality .... 

Diagnosis and prognosis . 
Examination for the spirillum 



CHAPTER V. 

The Treatment of Cholera . 
Prevention .... 
Quarantine .... 



CONTENTS. 


VI 1 


Disinfection 


PAGE 

77 


Haffkine's cholera vaccine .... 


86 


Medicinal treatment of cholera 


88 


The use of acids 


89 


of anodynes and astringents . 


92 


of antiseptics 


94 




96 


Enteroclysis 


97 


The use of opium 


100 


Intra-venous infusion of salines . 


102 


Hypodermatoclysis 


107 


Subcutaneous injection of sodium phosphate 


111 


Lavage of the stomach 


113 


Klebs's anticholerine 


115 


Injection of caffeine 


116 


of chloral 


117 


Warm baths 


118 


Injection of pilocarpine .... 


119 


Prof. Rumpf 's treatment at Hamburg . 


122 


Prof. Cantani's treatment .... 


123 


Treatment at the Paris hospitals . 


124 


at the military barracks at Hamburg 


. 125 


at the New York quarantine . 


. 125 



CHOLERA. 



CHAPTER I. 

HISTOEICAL INTRODUCTION. 

Definition. — By the term cholera is meant not a 
flow of bile, as etymologically it signifies, but an 
epidemic disease pursuing the lines of travel and 
commerce, specific in character, because due to the 
presence and development of a special micro-organism 
and appearing at certain intervals of time. It is 
often designated Asiatic, or Indian cholera, from the 
country of its origin. 

Cholera morbus and cholera nostras are terms 
applied to a sporadic affection having similar symp- 
toms but arising from ordinary causes, and only 
occasionally fatal. 

Cholerine is an unscientific term, used to signify 
a mild form of cholera which it is supposed may 
develop into the genuine malady ; but there is no 
case of cholera without the bacillus, and hence if this 
organism be present, cholerine (so called) is cholera 



14 CHOLERA. 

and nothing else. The term is used to allay the ap- 
prehensions of the timid, to prevent loss to business 
and commerce, and to save the community from that 
state of demoralization which is apt to ensue when 
a grave epidemic is admitted to exist by official or 
professional authority. 

History. — It is not my purpose to write up the 
history of successive epidemics of cholera, but merely 
to indicate in outline the course pursued by the 
disease as a preliminary to the study of its etiology. 

It is quite certain that in its epidemic form, pro- 
ceeding from a centre or focus of infection to distant 
places, it is wholly modern. In the country of its 
origin it has been known from the remotest times. 
Its native home is the densely populated, malarial 
banks of the Ganges and Brahmaputra. Here the 
alluvial soil, the humidity, the isothermal lines, and 
the sanitary vices of an uncleanly and crowded 
population combine to form a suitable nidus for the 
germ of cholera. It was not, however, until 1817 
that it began its epidemic march. Why the disease 
manifested a new activity at this period and changed 
from the local to the migratory character is not 
known, and the only plausible explanation is that 
which refers the transport of the germ to the agency 
of those Mohammedan fanatics who went on an- 
nual pilgrimages to Mecca. It was not, however, 
until 1827 that cholera invaded Persia and Arabia, 



CHOLERA EPIDEMICS. 15 

and to this period must be referred the beginning of 
those great waves of epidemic influence that presently 
swept around the world, although previously to this 
by ten years it had passed beyond India In 1831 
cholera appeared iu Europe. In that year London 
was infected, and the disease was conveyed thence to 
Paris. 

The continent of North America was invaded by 
the great epidemic wave of 1832. It first overflowed 
Canada, and in the cities of Montreal and Quebec 
raged with great violence; New" York, Philadelphia, 
and other great centres of population beiug subse- 
quently infected. 

The epidemic of 1848, the next formal movement 
of the poisou from east to west, began its preparations, 
so to speak, in 1816 when it ravaged the holy places 
of Arabia, Mecca, and Medina, then crowded with 
pilgrims. By the returning caravans, cholera reached 
Egypt and Asia Minor, Cairo suffering especially, 
and Constantinople became a centre of infection in 
1847. Berlin was severely attacked in 1848 ; then 
Hamburg and London, and from London, as before, 
Paris received its infection, and was severely ravaged 
during 1849. To this country came the epidemic in 
1849, the disease entering by way of New Orleans, 
thence spreading through the great interior valley by 
the Mississippi, Missouri, Illinois, and Ohio rivers. 
The epidemic influence persisted to a greater or less 



16 CHOLERA. 

extent until 1854, and was especially remembered 
for its destructive ravages amongst the overland 
emigrants to California from the time of its arrival 
in 1849 until its final disappearance in 1854-5. 
The epidemic of 1865-6 was far milder than its 
predecessors, but was, nevertheless, quite active 
amongst the Prussian and Austrian military forces 
then operating in Germany, and was comparatively 
severe in some of the cities of our interior continent, 
where the local and climatic conditions are not unlike 
those of India. For example, the epidemic was not 
without energy in the city of Cincinnati, where I 
then practised medicine. As physician-in-chief to 
the Municipal Hospital, then established to receive 
cholera patients, I had the best opportunity for 
observing the disease. 

Since the epidemic of 1866, cholera has made one 
abortive attempt to develop a general susceptibility, 
and in various places there occurred local outbreaks, 
notably in the interior valley of this continent. At 
Cincinnati again, and other cities of the same region, 
some manifestations of infection were witnessed, but 
there was no general epidemic ; but the cases, about 
the genuineness of which there could be no question, 
possessed the proper clinical characteristics. Since 
the first appearance of cholera in the great interior 
valley, sporadic cases and limited local epidemics 
having all the clinical features of cholera have 



CHOLERA AT NEW YORK. 17 

occurred from time to time. Are they examples of 
true cholera ? Only a proper bacteriological investi- 
gation can settle this question ; but my present 
belief is that the comma bacillus has become natur- 
alized here under conditions so like those which 
obtain in its natural habitat, the valley of the 
Ganges, as to be able to maintain itself, if but feebly. 

During the past year cholera has again appeared 
in Europe (1892), but has manifested a disposition 
to infest special localities rather than prevail in a 
general epidemic. Hamburg, Havre, Paris, Mar- 
seilles, Berlin, have been visited, and the first named 
with special virulence. It is a curious fact that no 
connection can be established between Hamburg and 
other points of infection. Nothing is known of the 
source of the first case that occurred in that city. 
The epidemic was very severe in Havre. The 
infection was supposed to be derived from the 
suburbs of Paris, but the immediate links in the 
chain of communication seem wanting. The first 
case occurred July 15th, the second July 28th, and 
the third August 3, 1892, when the disease was 
already in active epidemic form in Hamburg. 

The arrival of vessels loaded with emigrants 
coming from infected ports to New York gave rise 
to most serious apprehensions throughout the United 
States. On the 30th of August the first vessel 
containing cholera aboard — the Moravia — arrived at 



18 



CHOLERA 



Quarantine, New York harbor. 1 There had been 
twenty-two deaths out of twenty-four cases of cholera 
on the passage from Hamburg to New York. Three 
days after the Moravia the Normannia and the Rugia 
arrived, both having cases of the so-called cholerine on 
board. In all, eleven vessels were detained at Quar- 
antine, with cholera aboard or threatened. So carefully 
was the quarantine maintained, and so successful was 
the result, that not a single case penetrated the cordon 
to infect the inhabitants of the city. Notwithstanding 
this, eleven cases, as to the diagnosis of which there 
can be no doubt, occurred in isolated localities in 
New York City. 2 Not one of these had any con- 
nection or association of any kind with Quarantine ; 
but one (No. 9) had any relations with the sea, and 
one was master of a canal boat. The fact that the 
cases had no topographical associations is clearly 
shown in the annexed diagram, for which I am 
iudebted to Dr. Biggs's article just referred to. The 
single fact common to the cases that may have some 
etiological significance is that they were occupied in 
business connected with the supply of foods, especially 
with animal foods. Not one of them became a centre 
of infection for other cases. In all of those in which 

1 Wilcox : The Cholera of 1892 in New York. The American Journal of 
the Medical Sciences, January, 1893, p. 58. 

2 History of the Recent Outbreak of Cholera in New York, by Dr. 
Herman M. Biggs. The American Journal of the Medical Sciences, 
January, 1893. 



CHOLERA AT NEW YORK. 



19 




20 



CHOLERA. 



the cholera spirillum was found— eight iu number 
out of twenty-six suspicious cases — death ensued, 
and only one of those died in which the bacillus 
was not found. 

"The first person affected with cholera in New 
York was taken ill the evening of September 5th, 
five days after the disease appeared in the harbor, 
and died September 7th." Dr. Biggs, in commenting 
on this remarkable behavior of cholera, says that 
" the high mortality iu the recognized cases in the 
city and the lack of any association render two 
suppositions probable : 

11 a. That a number of mild cases of epidemic 
cholera occurred in which the nature of the disease 
was not recognized. 

" b. That the cholera infection was in some way 
rather widely disseminated in the city." 

When Hamburg was attacked with cholera no 
communication could be traced with any infected 
locality, although various parts of Russia and some 
of the ports of the Black Sea, as well as at Baku, 
were then in the throes of the epidemic. The 
infection could not be traced from London to Paris, 
which in the former epidemics had been the route of 
transmission. The history of cholera, therefore, 
contains some unexplained problems, and much 
remains to be done to put in a clearer light its 
mode of diffusion as observed in successive epidemics. 



CHAPTER II. 

ETIOLOGY: THE CAUSES OF CHOLERA. 

In the study of the causes of cholera we discern 
two facts of supreme importance : the influence of 
bad hygiene — State, municipal, and personal ; the 
existence of a special germ, a pathogenic micro- 
organism — the comma bacillus. It can be asserted 
with confidence that these two factors must be in 
operation to produce cholera. 

The sanitary evils which prevail at the home of 
cholera and at those places where serious outbreaks 
have, occurred in the course of epidemics illustrate 
the conditions necessary to its evolution. In India 
the overcrowding of the population, the filthy habi- 
tations, the insufficient food, the disregard of the 
most ordinary precautions for the disposal of excreta, 
the contamination of the Ganges river — the only 
source of water supply — with cholera stools or with 
the washing of cholera-stained bed-clothing, the 
alluvial soil, the damp atmosphere — all combine to 
form a nidus ever prepared and maintained for the 
nurture of the bacillus. Similar conditions are found 



22 CHOLERA. 

to exist wherever cholera has effected a lodgment. 
Iii no places outside of India have the various 
sanitary evils active in the production of epidemics 
been more rife than at the holy places of Arabia 
during the Mohammedan pilgrimages. An instruc- 
tive narrative of these remarkable sanitary evils has 
lately been published by Dr. Sand with, of Cairo. 1 
He shows that in the last thirty-two years there have 
been sixteen severe epidemics of cholera in Arabia, 
affecting especially Mecca, Medina, aud the other 
holy places, and the deaths have sometimes reached 
as high as five hundred every day from cholera alone. 
This tremendous mortality ceases to be surprising 
when the remarkably unsanitary state of the holy 
places is understood. During the pilgrimages of the 
faithful as many visitors crowd into the cities as the 
permanent population, which is itself more than suffi- 
cient to fill the available space. It is stated by Dr. 
Sandwith that as many as thirty adults are packed into 
a room only large enough for two or three even when 
closely placed. The heat is great, and the air is laden 
with dust and foul odors. The cesspools are never 
cleaned, aud consequently the liquid part runs over 
into the streets, and more or less finds its way into the 
water reservoir. The water for the city of Mecca is 
drawn from the Ain Zebaida and is conducted to an 
open cistern, or pool, about three hundred feet in 

1 The New York Medical Journal, February, 1893. ' 



THE CAUSES OF CHOLERA. 23 

diameter, and this must supply the population. 
The water becomes putrid with the decomposition of 
animal and vegetable matter, and has a nauseous 
taste. Thousands of cattle and sheep are sacrificed 
every day, and the blood and offal remain to 
decompose ou the ground. All day the dirty, 
unkempt pilgrims crowd the Kaaba, and the air 
becomes unspeakably foul. When cholera is intro- 
duced the germs fiud ready access to the drinking- 
water and to the food, and heuce very soon a large 
part of the population, already prepared for the 
reception and development of the germ, become 
infected, and the disease runs riot. 

During the present epidemic several instructive 
examples of the influence of bad hygiene on the out- 
break of cholera have beeu brought to light. I do 
not now allude to the epidemics that have prevailed 
in the unhealthy parts of cities, as Hamburg, Havre, 
Paris, Marseilles, but to certain strictly localized 
outbreaks, such as that at Nietleben Asylum, near 
Halle ; at the asylum and prison of Nanterre, near 
Paris; and at Portal, near Boulogne, during last 
year's epidemic. The occupants of these asylums 
and prisons are subjected to certain special influences 
besides those that obtain in the district or com- 
munity in which the institutions are situated ; they 
are crowded and confined to close, ill-ventilated 
apartments ; they have poor food, insufficient or no 



24 CHOLERA. 

exercise, aud they experience much mental and 
moral depression and anxiety. Although the village 
of Nietleben and the city of Halle near by were free 
from cholera, the inmates of the asylum suffered 
severely. The water supply was derived from the 
same source, the river Saale. No explanation of the 
outbreak was forthcoming, and its spoutaueous origin 
was being practically accepted when it was ascer- 
tained that an attendant had come from Hamburg 
during the time the epidemic was going on in that 
city, aud it was further learned that some suspicious 
cases had happened in the asylum months before. 
So unfavorable were the local conditions at Nanterre 
that 95 per cent, of the cases of cholera died. 

The epidemic at the small seaside town of Portal 1 
was very severe ; of 132 cases there were 76 deaths. 
Here there is every reason to suppose that the germs 
were introduced from Paris, there being constant aud 
uninterrupted communication with Boulogne, of which 
Portal is a suburb. The water supply is derived 
from shallow wells. Some of the houses have cess- 
pools discharging into the subsoil ; some have pails 
which are emptied, when convenient, out into the 
streets or on some rubbish heap. That there should 
be an epidemic in Portal under these circumstances is 
not surprising. 

Climate in itself has little influence over the 

1 Lancet, March 11, 1893, p. 550. 



THE CAUSES OF CHOLERA. 25 

progress of cholera ; it prevails under all possible 
conditions within the tropics, and within or near the 
arctic circle. Severe epidemics have occurred in St. 
Petersburg and more remote northern cities in 
midwinter. A humid state of the air as distinctly 
promotes as a dry state retards an epidemic. A 
moderate rain, a mist or fog, and a still atmosphere 
are favorable to the development of the germ, and 
often precede an outbreak of the disease. It is 
because of the dryness of the air and of the soil that 
pilgrims returning from Mecca by caravan through 
the desert are often freed from the cholera infection, 
so that the disease reaches Cairo but occasionally by 
this route. 

Elevation retards the epidemic influence en route. 
It may leap over a lofty mountain chain, but it 
rarely prevails at an altitude greater than three 
thousand feet above the sea level. Yet in 1892 there 
was a formidable epidemic in the valley of Kashmir, 1 
about 5200 feet above the sea level. The principal 
city, Srinagar, contains 125,000 people in "25,000 
low, dirty houses, built irregularly on narrow lanes 
and alleys, which are used as latrines. There is no 
drainage, and the storm- water washes the filth and 
ordure into the Nalla Mar and into the river from 
which the drinking-water is obtained." 

1 The Cholera Epidemic in Kashmir, by A. Mitra. Quoted in the 
American Journal of the Medical Sciences, February, 1893, p. 232. 



26 CHOLERA. 

Cholera follows the lines of travel, and hence may 
proceed against or with the prevailing winds. It has 
often been observed that if the cholera poison diffuses 
with the air it should be carried in the direction of 
the winds, and that it is not so carried has always 
been an embarrassment to those who find in air 
currents the vehicle of its trausport. In the same 
way, according to Pettenkofer, the " ground water " 
serves as a means of securing the dissemination of 
the poison. The Munich Professor has long main- 
tained his theory, and still adheres to it, despite 
Koch's discovery of the comma bacillus. The surface 
water acts as a culture medium from his point of 
view. Much depends on the character of the soil. 
In a very dry, sandy soil the ground-water, to 
promote the development of cholera poison, must be 
comparatively high ; in a damp alluvium the ground- 
water must be low to be effective. Low-lying 
places, valleys, malarious situations are favorable for 
the spread of cholera. It is thus that cholera selects 
its point of development, and though the germs may 
be diffused through a continent, they become active 
only in situations where the ground-water, the soil, 
the humidity, and the bad hygiene coincide to make 
a suitable home. 

When cholera excreta are thrown upon the grouud 
they soon pass into the surface water, and this 
becomes the vehicle for contamination of the drinking- 



THE CAUSES OF CHOLERA. 21 

water. Cholera germs multiply rapidly in water, 
especially when it is contaminated with sewage. 

Cholera is not contagious in the ordinary sense of 
that term. It is Dot directly communicable from one 
person to another, and it is not necessarily active even 
when the poison is swallowed. During the epidemic 
of 1866 at Cincinnati I was in charge of the cholera 
hospital, and made many autopsies, yet neither myself 
nor any member of my family had any symptoms of 
cholera infection. It has long been known that no 
risk attends the contact with bodies dead of cholera, but 
handliug of the linen, clothing, bedding, and other 
objects about the patient is dangerous, especially the 
washing of the soiled sheets and clothing. The 
individual attacked with cholera must be in a recep- 
tive state ; the intestinal canal must be prepared for 
the germ, but it is not necessary that the ground- 
water serve as a vehicle for the preservation and safe 
conduct of the germ. Hence it is that causes 
producing a catarrhal state of the intestinal mucous 
membrane favor the development of the bacillus — 
such causes as the eating of unripe fruit, and unhealthy 
and indigestible food of all kinds, aud the drinking 
of beer and fermenting liquids aud spirits. These 
may be exciting causes. 

The male sex and occupation act as predisposing 
causes. Men are more exposed to the conditions 
favoring the reception and development of the germ, 



28 CHOLERA. 

but otherwise sex has no influence. Pregnancy is 
no bar to infection. Miscarriages occur, but, on the 
other hand, women go to full term and then die of 
cholera, au example of which I had at the cholera 
hospital ; a woman was brought in from some hovel 
in a moribund state, apparently at the end of utero- 
gestatioD. Certain occupations appear to favor the 
reception and development of the bacillus, notably 
those concerned with food supplies, especially animal 
foods. This was the one fact of au etiological kind, 
besides the presence of the comma bacillus, ascertained 
of the cases in the city of New York ; a majority of 
them were in some way connected with the prepara- 
tion and sale of various kinds of foods. 

Quite irrespective of the predisposing and exciting 
causes, above described, cases occur in every epidemic 
among those most favorably situated, amongst the 
well-to-do classes, admirably housed, and living 
under the best hygienic conditions. After an 
epidemic is well established and the material best 
fitted for the action of germs has been exhausted, 
the epidemic influence, unsatisfied, mounts higher 
and spreads more widely, and seizes in a strangely 
capricious manner its victims here and there ; but 
these peculiarities are a necessary feature of a disease 
caused by an infection distributed through the 
drinking-water. The data proving the connection 
between outbreaks of cholera and the use of drinking- 



THE CAUSES OF CHOLERA. 29 

water from special sources are very numerous and 
convincing. London epidemics have been remarkable 
for the variation in mortality when the local con- 
ditions were the same, except the supply of water. 
Of those districts receiving their drinking-water 
from the companies obtaining their supplies from the 
Thames river the deaths from cholera varied, 
according to the amount of sewage, from 8 to 163 
per 10,000 of population. Again, during the epi- 
demic of 1866 in London the mortality from cholera 
in the district supplied from the river Lea by the 
East London Company was 63 to 111 in 10,000 of 
population, whilst in the other parts of the city 
having an uncontaminated water supply the mor- 
tality was only 2 to 12 per 10,000. In 1854 a very 
severe epidemic of cholera broke out in Broad Street, 
in London, amongst the people using the water of a 
particular well, but the cases ceased when the well 
was closed. At Konigsberg, in 1866, cholera was 
very severe amongst those making use of water from 
the river Pregel, whilst those obtaining their supply 
from a distaut source, delivered through iron pipes, 
were but slightly affected. Facts of this kind have 
been frequently observed wherever cholera has 
existed : cesspools containing cholera dejecta, made 
to overflow by a sudden rainfall and their contents 
discharged into the neighboring wells, the water 
thus contaminated being made use of by the people of 



30 CHOLERA. 

a given area, amongst whom cholera has prevailed 
with great virulence. 

The history of the epidemic as it developed in 
Hamburg seems conclusive as to the agency of the 
drinking-water. Cases occurred at widely separated 
points simultaneously at the beginning of the epi- 
demic, aud yet the limits of invasion were restricted 
within certain well-defined areas. The cities of 
Altona and Waldeck are adjacent to Hamburg and 
the same conditions of soil and climate obtain in all 
of them, but each one has its own supply of water. 
Hamburg is supplied by the river Elbe, just above 
the harbor, and the water is delivered unfiltered. 
It is well known that the ebb and flow of the tide 
reached up to the source of supply, and that the water 
was contaminated not only with sewage but with a 
multitude of organisms and other organic matter. 
Altona also, obtains its water-supply from the Elbe, 
but higher up; and beside, has long made use of a 
system of sand filtration which has proved rather 
effective. Waldeck is supplied from an inland sea. 
That these cities escaped and Hamburg was so severely 
attacked when all the local conditions were the same 
except the water supply, indicates that to the agency 
of the drinking-water must be referred the epidemic 
influence that pervaded the one whilst the others 
remained exempt. 

At the recent conference on Cholera in the Russian 



THE CAUSES OF CHOLERA. 31 

Empire, which met in St. Petersburg last December, 
it was shown that pollution of the drinking-water 
was in almost every case the channel by which the 
disease was spread. The epidemic of 1892 (last year) 
prevailed along the river courses — the Volga, the 
Don, the Dnieper, and others. 

The following most instructive facts from the 
report of Dr. F. Clemow, on "Cholera in Russia," 1 
must also be mentioned : u In the village of Ulyby- 
shef (Vladimir government) a laborer arrived on 
June 29th from Kazan, where he had attended the 
funeral of his brother who had died from cholera. 
Three days later he sickened with the disease in the 
morning, and died the same evening. The clothes 
he had worn remained in an out-building for a week. 
They were then washed in a stream from which the 
village drew its water supply. In a very short time 
cholera became epidemic throughout the village. In 
the government of Viatka five villages situated along 
the banks of the same stream were invaded by cholera. 
The infection was traced to the systematic washing of 
linen belonging to the early cases in the stream which 
provided the inhabitants of the five villages with 
their drinking water. No sooner was this practice 
forbidden than the epidemic began to abate. In the 
village of Upper Moulla (Permskoy government) the 

1 The Lancet, London, May 6, 1893. 



32 CHOLERA. 

linen of cholera patients was washed iu a pond. 
From the same pond the inhabitants drew their 
supply of drinking-water, with the result that 
cholera raged throughout the village. ... As 
soon as the washing of linen in the pond was put a 
stop to, the number of cases of cholera began to 
diminish." 

Again — "In Great Bereznikof, a village in the Sim- 
birsk government . . . cholera attacked only that 
part of the village which drew its water supply from 
the river Kshi, whilst amongst the inhabitants of the 
other half of the village, whose drinking-water was 
derived from wells, there was but a single case— that 
of a beggar woman to whom some clothing from an 
infected house was given." Other instances of the 
same kind appear in this report. " In two villages 
of the Tambof government . . . cholera was con- 
fined to the inhabitants drawing their water supply 
from a pond contaminated by washing in it the linen 
of cholera patients, whilst those supplied by well- 
water not so contaminated did not have a single case 
of cholera !" I might adduce various examples of 
the same kiud from this report, but these must 
suffice. It is only in a country like Russia that 
instances of this kind can be so successfuly traced out, 
although every epidemic in all parts of the world, 
some of which have been already referred to, furnish 
us with illustrative facts showing the agency of 



THE CAUSES OF CHOLERA. 33 

drinking-water as a means of communicating the 
cholera infection. 

The weight of evidence is, therefore, clearly in 
favor of that view of the diffusion of cholera by 
drinking- water, which is now generally held ; but 
not all outbreaks are referable to this cause, for, as 
the facts at New York indicate, the occupation of the 
individual attacked seemed in some way, not now 
explicable, responsible for these seizures. 

None of the causes of cholera herein described, 
nor any combination of them, can really produce the 
disease in the absence of the specific germ. Petteu- 
kofer, the distinguished Munich sanitarian, maintains 
that three several conditions must coincide to produce 
a cholera outbreak, and these he represents by the 
algebraic signs x, y, z. If x stands for the poison or 
germ, y for the climatic state, the soil, and surface 
water, z will represent the state of the individual. 
If one of these be wanting there can be no cholera. 
As has been intimated, with Pettenkofer the soil with 
its ground- water is a kind of culture-field where the 
cholera poison must undergo preparation for activity. 
Professor Arndt, of Griefswald, who has studied the 
explosive outbreaks at Nietleben Asylum and at 
Nanterre, and could not trace the introduction of the 
poison from without, came to the conclusion that it 
was " home-grown " — an example of spontaneous 
generation, it might be supposed, but really an 



34 CHOLERA. 

exaltation of the virus by successive cultures in the 
local media of filth. Professor Peter maintains the 
spontaneous origin of the cholera virus under the 
circumstances of crowding, impure water, foul air, 
unhealthy habitation, bad food, etc. 1 Other bacilli 
— for example, the spirillum of Finkler — it is pos- 
sible, may, by spontaneous changes in the media 
about them, develop into the pathogenic forms. 

The agency of living organisms has long been 
invoked to account for the propagation of cholera, 
and every epidemic has witnessed the discovery of 
an organism supposed to have pathogenic relation 
to the disease. It was not possible to differentiate 
the various forms found in the cholera dejecta until 
the means of culture and staining, followed by 
experiments on animals, came to be understood. It 
was reserved for Koch to demonstrate the micro- 
organism of cholera. Sent out, in 1884, to India at 
the head of a commission to study cholera in its 
home, Koch soon differentiated the form now to be 
known as the comma bacillus. At first his state- 
ments were received with some incredulity, but the 
recent studies at Hamburg, at the Moabit Hospital 
in Berlin, at New York, and elsewhere, have fully 
confirmed his conclusions at all points. The doubts 
entertained at first with regard to the comma 
bacillus arose from the circumstance that the 

1 Lancet, March 4, 1893, p. 49. 



THE CAUSES OF CHOLERA. 35 

inferior animals are not, as a rule, affected in a way 
to justify the opinions of its toxie powers ; but with 
proper care and by introducing the cultures into the 
intestinal canal, mice and guinea-pigs have been 
characteristically affected, and what is more signifi- 
cant, the human subject, in the notable cases of 
Pettenkofer, Emmerich, Hasserlik, and some others, 
having been experimentally acted on by the direct 
introduction of the germs by swallowing, afforded 
the clearest evidence of a toxic action. That a 
given organism be considered specific it must fulfil 
these conditions : It must always be present in the 
disease in question ; it must be cultivated in suitable 
media and separated from all other forms ; in its 
growth and development in these media and apart 
from the body it must always conform to the 
original type ; when these cultures are introduced 
into the bodies of animals susceptible to their action 
they must cause a disturbance like the original 
malady in respect to the symptoms and changes of 
structure ; the parasites must be found again multi- 
plying in the secondary subject. These conditions 
complied with, there can be no doubt that such 
germs are specific and pathogenic. 

The spirillum of cholera was designated by Koch 
as the comma bacillus, because of its resemblance to 
the comma (,) of written and printed language. It 
has an arc-like body, slightly twisted on itself, 



CHOLERA 







In Fig. 2 we have a representation of the spirillum, unstained, in a 
cover-glass preparation. In Fig. 3 the bacilli are more distinct and 
separate, and were in the original stained. 




From Dr. Dunham's paper "On the Bacteriological Examination of the 
Cases of Cholera in New York." 



THE CAUSES OF CHOLERA. 87 

spiral, rounded at one extremity, and contains at the 
end flagella. It is motile and about half the size of 
the bacillus tuberculosis. It is anaerobic, that is, 
thrives best without oxygen, but it can live in the 
presence of oxygen. The comma bacillus grows 




From Dr. Dunham's paper. 

Figs. 4 and 5 are cover-glass preparations under a much higher power— 
700 diameters. These figures are copied from photomicrographs. Of 
course, the hacilli must he carefully distinguished from the matters in 
which they are imbedded, and from air bubbles. Compare the forms in 
Fig. 3 with the same to be seen in Figs. 4 and 5. 

readily in various nutrient media having an alkaline 
reaction, and can be cultivated easily. It takes the 
aniline stains, and is colored with fuchsine solution. 
It liquefies gelatin. Such are the main character- 



38 CHOLERA. 

istics of the micro-organism of cholera. 1 In Figs. 2, 
3, 4, and 5 we have a representation of the bacillus 
as seen in cover-glass preparations, for which I am 
indebted to the article of Dr. Duuham, of New York, 
except Fig. 3, which, with Fig. 6, is from Koch. 



i M¥'/ / 'J I / 



i 

Tlie bacillus in cholera dejections on a sheet. (From Koch.) 

The cholera bacillus is contained in the dejections 
of a cholera subject — in the matters vomited and 
passed by stool — the so-called rice-water discharges. 
These thrown out on the ground where there are 
human habitations find access to the wells and 
springs, and to water-courses, and thus in drinking 
water are disseminated. In high northern latitudes 

1 Grundriss der Bakterienkunde. Von Prof. Dr. Carl Frankel. Dritte 
Auilage. Berlin, 1890. 



THE CAUSES OF CHOLERA. 39 

the cholera dejecta thrown out on the snow soon 
reach the intestinal canal of man, because melted snow 
is used for drinkiug-water and culinary operations. 
Hence it is that cholera seizes so many and is so 
destructive in the far north when an epidemic is 
prevailing. Cold merely inhibits the parasite but 
does not destroy its vitality. It has been shown 
that the bacillus flourishes in water containing 
organic matter and alkaline from the presence of 
ammonia. It is not known how long it will pre- 
serve its vitality in the water of running streams. 

We have some carefully conducted experiments to 
illustrate the viability of the cholera bacillus when 
attached to various articles. Uffelmann, 1 in a recent 
paper, has shown that the bacillus on the surface of 
rye bread open to the air remained alive for twenty- 
four hours, but when the bread was wrapped in 
paper it continued viable for three days. On roasted 
meat, placed under a bell jar, the spirillum was 
active at the end of a week ; on the printed page 
seventeen hours ; on writing-paper in an envelope 
twenty-four hours ; on the hand, somewhat more 
than an hour ; on silver and copper coins, a half 
hour only ; on textile fabrics, in a dry state, four 
days, but when moist they continued viable more 



1 Berliner klin. Wochenscbr., 1892, No. 48. Quoted by Sternberg— The 
Practitioner, March, 1893, p. 235. Also, The American Journal of the 
Medical Sciences, March, 1893, p. 357. 



40 CHOLERA. 

than twelve days. The observations published by 
the Imperial Board of Health, of Germany, on this 
subject are very important. It was ascertained that 
the bacillus was active when on fresh fish about two 
days ; on salted and smoked herring only one day ; 
on sweet cherries three to seven days, sour cherries, 
three hours ; strawberrries, one day ; on pears two 
to five days ; cucumbers, five to seven days ; on 
dried fruits one or two days. As regards fluids, the 
germs were active as follows : In beer for three 
hours ; white wine, five minutes ; red wine, fifteen 
minutes; cider, twenty minutes; cold coffee, two 
hours; milk, not sterilized, twenty-four hours, and 
milk sterilized, still living at the end of nine days; 
tea, two per cent, infusion, four days. From such 
data we readily see how the germs of cholera can be 
conveyed. The poison may be carried by the non- 
infected to others who have become susceptible with- 
out experiencing the action of the poison. The inter- 
mediary may unload his burden of infectious 
material at a long distance from the point where it 
was taken up, and thus the source whence the 
infection was derived remains unknown. By the 
potable waters of rivers, by paper money, by various 
foods, and similar accidents, contamination may be ef- 
fected and all intermediary agencies remain unknown. 
The house-fly should not be overlooked — for Uffel- 
manu found that two hours after walking through 



THE CAUSES OF CHOLERA. 41 

cholera dejecta flies could infect nutrient media. It 
follows from these facts that the most mysterious and 
apparently inexplicable outbreaks are still capable of 
explanation. 

It is not alone necessary that the comma bacillus 
be present for an attack of cholera to occur. 
Individual susceptibility must coexist, and the spir- 
illum must gain access to that part of the body where 
a suitable nidus is formed for its growth and devel- 
opment. That part is the intestinal canal of man. 
No other part of the body furnishes the necessary 
conditions, and even this part proves inhospitable 
unless some preparatory changes have taken place to 
render it a suitable nidus. It is in respect to this 
that such etiological factors as improper food, spirit 
and beer drinking, exposure to cold and dampness, 
and other factors promoting a catarrhal process and 
an alkaline reaction prepare the way for the reception 
of the germ and its pullulation. It can hardly be 
doubted that the germ must reach the intestinal canal. 
If breathed with the air it must lodge in the mouth 
or fauces and be swallowed ; if contained on the 
hands or under the finger nails it must attach itself 
to some articles of food • if paper money be soiled 
with it, or articles of clothing, they must impart their 
infection to the food or drink. All the facts tend to 
show that the drinking-water is the most important 
vehicle for conveying the poison to the intestinal 



42 CHOLERA. 

canal of man. That the spirillum is found with 
difficulty and in relatively small proportion in the 
waters of rivers and running streams does not alter 
the great fact. 

I must not fail to describe with more particu- 
larity as respects the agency of the spirillum in 
the production of cholera, the striking experimental 
data in the voluntary infection of Hasserlik and 
four others of Vienna, and of Profs. Pettenkofer 
and Emmerich, of Munich. We have exact par- 
ticulars of the experiments as carried out by the 
Munich professors. Pettenkofer swallowed one cubic 
centimeter of fresh bouillon culture of the bacillus, 
and, to obviate the action of the acid gastric juice, 
took at the same time one gramme of sodium 
bicarbonate. Diarrhoea commenced in thirty hours 
and lasted eight days. By the second day of the 
diarrhoea the stools had become almost colorless, but 
there was no nausea and the diet was continued 
unrestricted. There was a good deal of rumbling in 
the bowels and occasionally an imperious inclination 
to stool. Pettenkofer continued at his usual occu- 
pations and experienced no abatement of his bodily 
vigor. 

Emmerich repeated the same experiment, but 
in his case the results were more decided. The 
stools had at one time a distinctly rice-water charac- 
ter and there was considerable prostration. The 



THE CAUSES OF CHOLEEA. 43 

bacilli were found in large numbers in the stools of 
both experimenters. 

Petteukofer does not admit the specific action of 
the comma bacillus in these experiments ; but 
unprejudiced observers can hardly come to any other 
conclusion. Guttmann, 1 in commenting on these 
experiments, holds that they clearly indicate the 
specific character of the bacillus and that Emmerich 
had a mild attack of cholera aud Pettenkofer of 
choleraic diarrhoea. Posner, 2 of Berlin, also takes the 
same grounds, and maintains that the results of the 
experiments are conclusive of the toxic action of the 
germs. That not more severe results ensued in 
these cases was because they were not in a suscep- 
tible state, and that the gastric juice was not suffi- 
ciently neutralized. It has been suggested and 
is highly probable that the virulence of the bacilli 
had been lessened by repeated cultivation — a fact now 
known to be true. The germs swallowed by Petten- 
kofer had been sent to him from Hamburg, and 
were subsequently cultivated in bouillon, and, 
hence, it may be that the virulence of the toxiue had 
been reduced by these manipulations. Furthermore, 
it is generally understood that a predisposition to the 
action of the bacillus must be created ; the way must 

1 Deutsch. klin. Wochenschrift, No. 47, 1892. Quoted in the Practi- 
tioner and in the American Journal of the Medical Sciences, March, 1893. 

2 The Practitioner, ibid. 



44 



CHOLERA 



be prepared for the reception of the germ, and the 
conditions necessary for its growth and development 
must be arranged in advance. These experimentalists 
suffered quite as severely from the taking of the 
germs as might a 'priori have been expected, aud 
only the most prejudiced minds can fail to see the 
relatiou between the swallowing of the germs and the 
considerable intestinal disturbance that followed in 
every case. 



CHAPTER III. 

THE SYMPTOMS OF CHOLERA. 

The symptoms of cholera are naturally divisible 
into four groups : 

1. The Prodromal or Diarrhoea! Stage; 

2. The Systemic Infection ; 

3. The Algid Period ; 

4. Reaction, or The Typhoid Stage. 

1. When an outbreak of cholera is about to ap- 
pear, a general tendency to relaxation of the bowels 
is sometimes manifest, or cases of diarrhoea are more 
common, or slight errors of diet more easily than is 
usual, cause intestinal irritation. This general state 
may be likened to the " epidemic constitution " of 
Hippocrates ; it indicates the existence of a special 
susceptibility ; it seems to imply that a universal 
though occult cause is in operation. In view of what 
is now known of a cholera germ, it may be assumed 
that it is beginning its active life, not yet attaining to 
its highest powers, but growing on the surface of the 
mucous membrane, and thus exciting a disturbance — 
an intestinal catarrh of limited extent, but not a 



46 CHOLERA. 

fully developed seizure. After the first few mild 
cases of an opening epidemic, the most severe cases 
occur at the beginning, and as the epidemic influence 
declines the susceptibility lessens, and the severer 
types cease to appear. 

Although it is usual and correct enough to say 
that a tendency to diarrhoea is the first real manifes- 
tation of a cholera seizure, yet close inquiry will 
usually develop the fact that some vague sensations 
of depression, of chilliness, of weakness, precede the 
diarrhoea. Some uneasiness is felt about the umbili- 
cus, there is rumbling in the bowels, aud a sense of 
relaxation is experienced. It often happens that 
without any warning a large watery stool is evac- 
uated, and the diarrhoea sets in with sudden violence. 
No pain is felt with the stools, rather relief to a sense 
of distention, and the fluid evacuation pours out 
noisily ; it is thin, light in color, yeasty in appear- 
ance and has a mouse-like odor. In old subjects the 
discharges may be tinged with blood, or at any age 
they may have a faint greenish tint or brownish, but 
usually they soon become whey-like or rice-water- 
like and contain whitish flocculi and masses of yeasty- 
looking material floating about or settling on the sides 
and bottom of the close stool. The call to stool is 
usually sudden — so sudden that often the clothing and 
the bedding are stained from inability to control the 
sphincter. The discharges are composed of blood- 



CHOLERA DIARRHOEA. 47 

serum, intestinal epithelium, urea crystals of triple 
phosphate and ammonium carbonate, and the reaction 
is alkaliue as a rule, although it may be neutral. 
Numerous organisms are found, as also the indispen- 
sable comma bacillus. The number of bacilli is not 
a necessary indication of the severity of the seizure, 
for the attack may be a mild one when there are large 
colonies present, and a severe one when there are but 
few ; nevertheless the rule is that the number and 
activity of the parasites afford a measure of the vio- 
lence of the disease. The diarrhoea is apt to come 
on after midnight — after some hours of unquiet sleep, 
or toward the early morning, and a few violently ex- 
plosive discharges copious in quantity usher in the 
algid state. Or, beginning in the after part of the 
night, the diarrhoea persists during the day, the stools 
gradually assuming the characteristic appearances, 
becoming light in color, then whitish, more fluid, 
yeast-like, more alkaline in reaction — more distinctly 
the real rice-water evacuation, as the day wears on. 
In some instances the diarrhoea goes on in the man- 
ner of an ordinary diarrhoea, and then suddenly as- 
sumes the characteristic form, becomes copious, 
watery, rice-water-like, and almost immediately the 
patient passes into the algid state. Vomiting, with 
little or no nausea, and hardly more than merely the 
act of regurgitation, appears at varying times during 
the diarrhoeal stage, usually, of course, at the ap- 



48 CHOLERA. 

proach of systemic infection. If treated at an early 
period, the diarrhoea is usually arrested, aud hence 
must remain the doubt, in the absence of a bacterio- 
logical examination, whether the case is one of true 
cholera. When an epidemic of cholera is at its 
maximum of activity, the diarrhcea manifests a less 
manageable disposition. Although paiuless, the dis- 
charges are noisy, explosive, and little modified, if 
any, by the measures employed, and certainly not 
stopped in the gravest cases. The circumstances in- 
fluencing the violence of the cholera diarrhcea are 
probably more the condition of the individual attacked 
and his immediate surroundings, than the state of 
the germ. When improper food has set up an active 
intestinal catarrh, or other causes have been in opera- 
tion to bring about the same kind of disturbance, we 
may suppose, by way of example, that the bacillus 
finds in this state a suitable culture field for its growth 
and development, and is hence less amenable to 
treatment. 

2. The Systemic Infection. No well-marked bound- 
ary separates the prodromal from the infection stage. 
Usually some chilliness and a general malaise, not 
very well defined, are experienced. Some weakness 
is felt, nausea comes on aud with little w r arning vom- 
it ing occurs. Like the stools, the vomit comes up 
easily, quickly, and with little preliminary disturb- 
ance. First, any food present is brought up, then 



SYSTEMIC INFECTION. 49 

mucous and bilious matter, and very soon — usually, 
indeed, at the second vomiting — a quantity of whey- 
like fluid, the rice-water matter, comes boiling up by 
an act rather of regurgitation than of strenuous vom- 
iting. Like that passed by the bowels, the matter 
regurgitated from the stomach is alkaline iu reaction, 
and is composed of the serum of the blood, epithe- 
lium in great quantity, phosphate salts, carbonate of 
ammonia, urea, and numerous organisms, amongst 
which are found the spirillum of cholera. The tongue 
is cool, sticky, and the mucous membrane covered 
with a whitish layer of the cast-off epithelium. There 
is much thirst, and the water drunk is quickly 
brought up again. 

There is now a general depression of the forces ; 
the patient feels weak and unequal to effort, the pulse 
is weak and rather quick than slow, the tension some- 
what unequal. The urine becomes scanty, and then 
none is passed, and when the catheter is used but 
little, if any, is brought away. The urine at an 
early period contains albumin, tube-casts of a granu- 
lar character, and a great deal of epithelium and car- 
bonate of lime, but the urea is comparatively small in 
quantity. Most patients become apathetic, indiffer- 
ent, and lie in a somewhat somnolent state, eyes half 
closed ; others are restless, sighing and tossing rather 
wildly about the bed, and full of the horror of the 
situation. The respiration declines in force and vol- 



50 CHOLERA. 

ume, and varies in rhythm, having a rather sighing 
character. The expired air is cool. The voice be- 
comes husky and distant ; the countenance is dull 
and dusky in hue ; the face is beginning to shrink, 
the eyes to become retracted. 

Thus far but little distress except the feeling of 
weakness, and some intestinal uneasiness, are expe- 
rienced, but with the stage of infection muscular 
cramps occur first, and chiefly in the muscles of the 
calf, then in the arm, and at length in the voluntary 
muscles generally, even the muscles of the larynx, 
of the ear, and occasionally the intestinal muscular 
layer being attacked. When the cramps are severe, 
the muscles are drawn up into hard knots, and cause 
intense paiu, so that the patients shriek out in their 
agony. I have often heard these cries in the night 
as I have passed along the street on my way to the 
bedsides of others sick with the disease, during the 
epidemic of 1866. As the muscles contract with the 
cramp, the action of the heart gets slower and weaker, 
and for a time the pulse may disappear. These 
cramps are, in part, due to the extreme loss of fluid, 
and to anaemia of the muscles, but chiefly due, as I 
think, to the action of the cholera toxine on the 
medulla oblongata. 

3. The Algid Stage. The profuse watery evacua- 
tions, the loss of serum from the veins, the desqua- 
mation of the epithelium, cause rapid failure in the 



THE ALGID STAGE. 51 

vital resources. The pulse at the wrist, at first un- 
equal in tension and fluctuating iu force, declines in 
strength and volume until at length only a faint 
vibratory trembling can be felt, or it ceases alto- 
gether. The sounds of the heart are barely audible, 
and the apex beat makes no impression on the chest- 
wall. The countenance is bluish or cyanosed, re- 
tracted and shrunken ; the lips drawn back, exposing 
the teeth ; the eyes deeply sunken in the orbits and 
surrounded by dark circles ; the vision is dim, the 
pupils contracted; conjunctivas injected; the voice is a 
mere husky whisper, and a pause is needed between 
every word to gather the strength required to utter 
the sound — vox cholerica — the hearing is dull and 
there is singing in the ears, the external ear is of a 
bluish, or brownish-purple tint ; the breath is cold, 
and the movement of respiration is slow, shallow and 
sighing ; the surface of the body is cold, the skin 
shrunken, and sodden like the hands of a washer- 
woman ; the face, neck and extremities, both upper 
and lower, are more or less deeply cyanotic, the toes 
and fingers incurved, retracted, and rigid with cramp 
— such is the complex of symptoms of the algid stage 
as ordinarily witnessed. 

The coldness of the surface is represented, of 
course, in the lower range of the thermometer, but 
not wholly so. The surface is cold to the touch, 
when the actual body heat, as shown by the thermom- 



52 



CHOLERA, 



eter, is not much, if any, below the normal, and not 
sensibly much colder when the temperature is regis- 
tered as low as 92° F. The usual thermometry 
range is from normal to 94° F., but the body tem- 
perature has been known to fall as low as 88° F. in 
the axilla, aud a few instances have been reported in 
which it is said to have descended as low as 82° F. 
The rectal temperature is higher than the surface 
temperature, aud its range between extremes is less 
exteusive. The loss of the blood-serum and the 
damage to the red blood globules, limit or suspend 
oxidation, and the outward diffusion from the veins 
increases heat dissipation. Hence it is that the pa- 
tient in the algid stage grows cold as a frog, becomes 
apathetic and indifferent to his fate, somnolent or 
stupid, or actually passes into a comatose condition. 
Although lying thus in the lowest state compatible 
with existence, sometimes his muscular strength is 
preserved iu a marvellous degree. Without pulse at 
the wrist, patients have been known to get up unex- 
pectedly and wander about, aud some in bed along- 
side of each other have been heard to make bets re- 
garding the distance to which they could eject the 
vomit, aud on the dexterity with which they could 
deposit it in a given receptacle. It is probable that 
such patients had not reached the lowest algid state. 
There are cases that pass at once into collapse with- 
out any preliminary vomiting or purging; they are 



THE ALGID STAGE. 53 

stricken suddenly, and fall down where they happen 
to be with retracted features, cold surface and cyan- 
otic, an exceedingly weak pulse, slow and sighing 
respiration, and the usual muscular cramps. In 
such cases the abdomen is full and rather prominent, 
there is a distressing sense of distention, but no escape 
of rice-water matter occurs by vomit or stool. Hence 
such cases are designated cholera sicca, or the dry 
cholera. The diffusion from the veins and the des- 
quamation of the intestinal epithelium have occurred 
just as in other cases, but owing to a paretic state of 
the muscular layer of the bowel, the contents of the 
canal are not expelled, but remain. These cases are, 
in fact, of a severe type, as a rule, and profound in- 
toxication occurs, because of the increased absorption 
of the toxine, which is, also, we may suppose, pro- 
duced in greater quantity. In the epidemic of 1886, 
a case of this fulminant form came under my obser- 
vation, of a young lady in a well-to-do household in 
a large roomy mansion, in no way connected with the 
localities in which cholera had been occurring. She 
was taken whilst sitting in the parlor conversing 
with some friends, with sudden faintness, was carried 
to bed in a half-comatose state, and died within four 
hours after the first feeling of weakness came on. In 
other fulminant cases the patient lapses into coma 
and insensibility after one or two discharges by 
vomit and stool. In still other cases, a diarrhoea had 



54 CHOLERA. 

lasted for a day or two, but because painless, and the 
movements occurring at considerable intervals, it was 
not heeded, and the onset of the disease was referred 
to the profuse and tempestuous dejections ushering in 
the algid state ; but these are not properly examples 
of the fulminant form. 

In a considerable proportion of cases the vomitiug 
and purging cease when the algid condition is fully 
established, or the vomiting ceases, aud only an oc- 
casional stool occurs ; but it is soon found that no 
change has taken place in the other symptoms except 
that they are more severe ; no urine is secreted ; the 
pulse does not return to the wrist; there is increasing 
hebetube of mind, an actual asphyxia supervenes. If 
under such circumstances the vomiting and purging 
cease, only unfavorable conclusions must be drawn 
from this occurrence. 

4. Reaction Stage. Cases in the algid state that 
proceed to recovery — certainly not a large proportion 
— may simply convalesce, and in two or three days 
get well. Others pass into a typhoid state, and with 
the symptoms of uraemia linger for several days, at 
last dying comatose. Still others continue with the 
symptoms of diarrhoea or of dysentery, for a week or 
more, dying at last, or slowly recovering. 

Reaction may set in from the low stale in which 
life can hardly be said to exist ; the breathing which 
had been shallow, sighing, and at long intervals, 



THE TYPHOID STAGE. 55 

gradually gains in depth and force ; the pulse which 
may have been absent from the wrist begins to be 
felt again as a merely vibratory trembling under the 
finger ; the shrunken face and dusky countenance 
freshen up a little ; the eyes which were glazed and 
dull become more animated in expression ; the tongue 
which had become dry and brownish in color along 
its margins, now moistens, and the voice announces 
its return to use by a hoarse whisper. With the re- 
turning circulation the temperature rises again, 
approaches the normal and even passes above. In 
the most favorable cases convalescence is established, 
the urine is again secreted aud in increasing quantity, 
whilst the albumin lessens and presently ceases to 
appear; the stools become colored again, bilious in 
aspect, and although thin at first, soon become pro- 
perly consistent as digestion is resumed. The vom- 
iting stops finally ; some appetite now takes the place 
of an intense and insatiable thirst ; and with suitable 
food blood-making is actively resumed, and the 
strength restored. Such is the course when reaction 
occurs and convalescence is fully established. 

As already intimated, such a favorable course is not 
common. The physical law holds good here, as else- 
where — to every action there is an exact and equal 
reaction. When, therefore, the cholera subject is car- 
ried down into the lowest depths of the algid stage, 
the return must be by correspondingly severe and 



56 CHOLERA. 

difficult methods. The reaction is often incomplete. 
The functions are re-established in part only ; the 
bowels continue relaxed, and the stools assume a 
brownish tint, and have an odor of decomposition; 
the secretion of urine is insufficient and it continues 
albuminous ; the abdomen becomes distended, and 
gurgling in the right iliac fossa can be evoked by 
pressure as well as some tenderness. In other cases, 
besides a simple diarrhoea a dysenteric state is super- 
added and rectal uueasiuess with tenesmus are felt, 
with the distress belonging to ileocolitis ; the stools 
are rather large, offensive, and contain a good deal of 
mucus with some blood. So far as the intestinal 
canal is concerned, there are, therefore, two kinds ot 
reaction symptoms — diarrhceal and dysenteric ; but 
there is probably no case in which dysentery alone is 
present. The surface of the body is no longer cold, 
and the temperature rises into the febrile, with morn- 
ing remission and evening exacerbation. The mind 
is no longer merely apathetic, or occupied with vague 
terrors, but there is drowsiness, if not actual stupor, 
and some muttering delirium, picking at the bed- 
clothes and subsultus tendinum, or a condition ot 
coma vigil comes on. 

Such is the symptom complex which presents itself 
in the typhoid stage of cholera. If symptoms, such 
as headache, coma, twitching of the muscles, and 
especially if convulsive phenomena ensue, and the 



THE TYPHOID STAGE. 57 

urine is especially meagre, or wanting, the case is 
one of the urseniic form. 

During the algid stage, and especially during the 
period of reaction, various eruptions appear on the 
skin. More frequently than any other it has a 
measles-like form, is punctated, discrete, and reddish- 
brown in color. It is more abundant about the fore- 
head, the eyelids, and the forearms, than elsewhere. It 
is sometimes urticaria-like, and rarely has the appear- 
ance of erythema nodosum. The punctations of the 
measles-like eruption, as seen on the abdomen during 
the typhoid stage, present a superficial resemblance to 
the typhoid eruption. 



CHAPTER IV. 

PATHOLOGY AND MOEBID ANATOMY OF 

CHOLEEA, 

Immediately after death the temperature of the 
body may rise several degrees above the normal. 
After the subsidence of the body heat, the post-mor- 
tem rigidity sets in promptly. In all cases the mus- 
cular rigidity is considerable, not unlike that of 
tetanus, and persists for several hours; the hands 
and feet are incurved, and the joints stiff to immo- 
bility unless some force be used. The neck and face 
still exhibit the cyanosis and venous stasis which are 
such marked features during life, but they are now 
supplemented and intensified by the post-mortem 
congestion. The face is shrunken and dusky; the 
eyes are deeply sunken and still surrounded by a 
dark areola ; the mouth is retracted and the lips fixed 
in a rims sardonicus, and the teeth, covered with 
sordes, are exposed. The abdomen is prominent or 
retracted ; when there has been neither vomiting nor 
purging, prominent ; but when the contents of the 
canal have been freely discharged, the abdomen is 
retracted. 



PATHOLOGY AND MORBID ANATOMY. 59 

The tissues are generally dry, the veins collapsed 
except those of the intestine, and the body throughout 
is exsanguine. The intestines have, as a rule, a 
uniform rosy tint ; the peritoneum is dry and sticky, 
the folds of the intestine adherent, but there is no 
inflammatory exudation to bind them together. If 
the intestines are " stripped" between the thumb 
and fingers from above downward, a quantity of 
fluid and semi-fluid whitish rice-water matter can be 
forced out, and is found to consist almost wholly of 
the intestinal epithelium, with many micro-organisms, 
including the bacillus. The solitary glands of the 
mucous membrane, throughout the whole tract, are 
enlarged, but peculiar appearances are found in the 
small intestines. The veins of the ileum are promi- 
nent, the solitary glands, the patches, the follicles, 
are swollen and prominent, and the "shaven-beard" 
appearance is very marked in places, more especially 
in the case of those subjects dying during the reaction 
or typhoid stage. The longer the case continues 
after the algid stage, the more pronounced the 
changes, in their completest development consisting 
of oblong patches of thickened glands studded be- 
tween with black points, the orifices of Lieberkuhn's 
follicles, whence the homely designation of shaven- 
beard appearance. The epithelium of the mucous 
membrane, notably the columnar epithelium of the 
villi, if not detached, leaving the basement membrane 



60 CHOLERA. 

bare, is more or less advanced in fatty degenera- 
tion, and loosening, and the villi are often in a state of 
necrosis. This condition of the epithelium was a 
constant phenomenon in former epidemics, and was 
noted in the intestinal canal after death, as in the 
dejecta passed during the progress of the case. Dur- 
ing the late epidemic in Hamburg, at Berlin (the 
Moabit Hospital) and elsewhere this state of the 
epithelium was also observed. The comma bacillus 
penetrates into the villi, and into the follicles of 
Lieberkuhn, and where an ulcerated surface gives 
them an entrance, into the deeper tissues ; but they 
are not found in the blood, nor in any organ or part 
outside of the intestinal canal. They do not persist 
throughout the whole course of every case ; in some 
they disappear early, and in others are not encoun- 
tered after the twentieth day. 

The liver besides an excess of black blood ex- 
hibits no special change, except the desquamation of 
the epithelium lining the ducts. In 1866 I found 
the gall-bladder distended with bile, but there was 
no bile-staining of the common duct. The spleen 
has been represented in two conditions ; as enlarged 
and flaccid, as firm and small or normal — the former 
being found when the case had continued on to a 
typhoid or uramiic stage. 

The heart muscle is usually well contracted and 
the cavities empty, or they contain some rather dark 



PATHOLOGY AND MORBID ANATOMY. 61 

clots in the case of early fatal termination ; it is flac- 
cid, and its substance easily torn, in the cases fatal 
after a more or less prolonged typhoid stage. Some 
fluid black blood, or some loose tarry clots, are some- 
times found in the right cavity only. The pericardium 
has the same dry state and the same adhesiveness as 
the peritoneum. The pleura is also sticky and dry, 
the surfaces adhering. The lungs are dry, exsan- 
guined, and collapsed, but no special lesions occur in 
these organs. 

Besides the fulness of the veins of the meninges, 
and the characteristic dryness, there are no changes in 
the brain proper. A very evident hyperemia of the 
medulla oblongata I observed to be a constant phe- 
nomenon in the epidemic of 1866, and there seemed 
to be a certain proportion between this congestion of 
the medulla and the muscular cramps. The expla- 
nation of this is not far to seek. The cholera toxine, 
we may suppose, has a selective action on this part of 
the nervous system, as strychnine or conine. The 
germs themselves do not get beyond the intestinal 
canal, but the toxine they elaborate is absorbed, and 
reaches distant parts for which it may have a special 
affinity. 

The kidneys exhibit characteristic alterations. 
They are rather large and flabby, of a faint reddish 
tint or white and smooth. The epithelium of the 
tubules is affected with " cloudy swelling " and 



62 



CHOLERA. 



undergoes fatty degeneration ; it is loose and desqua- 
mating or readily detached. Little or no urine is 
found in the bladder ; any present contains albumin, 
abundance of epithelium, casts, much lime salts, etc. 
According to Reiche 1 hemorrhagic infarctions are 
found in the endometrium in 65 per cent, of the cases 
of adult women, and hemorrhage into the stroma of 
the ovaries is, also, not uncommon ; but these changes 
can have no relation to the disease as it manifests 
itself during the life of the patient, nor are they 
essential elements in the morbid complex. 

From the data now before us it is possible to con- 
struct a consistent theory of the pathology of cholera. 
In some manner, whether by the agency of food or 
drink, or by other vehicle of infection, the comma 
bacillus finds its way into the intestinal canal of man. 
If the mucous membrane is in a receptive state, if 
there be present no hostile organisms— no phagocytes 
—to destroy the bacillus, it lodges, undergoes de- 
velopment, produces its own kind, and also manu- 
factures a toxine— an organic poison— that being 
absorbed affects the system at large. The local irri- 
tation of the mucous membrane caused by improper 
food, by alkaline fermentation, by alcoholic drinks, 
etc., prepares the way for the spirillum, makes easy 
its growth and pullulation, and so changes the local 

» The Cholera in Hamburg : Dr. Reiche. The American Journal of the 
Medical Sciences, February, 1893. Translated by Dr. A. A. Eshner. 



PATHOLOGY AND MORBID ANATOMY. 63 

conditions that the diffusion of liquids is from the 
vessels outward into the canal, instead of inward 
from the intestines into the bloodvessels. In the 
midst of these favoring circumstances the spirillum 
multiplies exceedingly — they penetrate into the folli- 
cles, into the epithelium of the villi, and more deeply 
into the tissues should an ulceration offer the means 
of so introducing them. How much the mere growth 
of the bacillus contributes to the changed physical 
condition, causing diffusion of the blood serum out- 
wardly, or how much may be due to the toxine after 
its absorption, is impossible to say. The great out- 
pouring of fluid, and the enormous discharge of the 
rice-water matter, must necessarily lessen the fluidity 
of the blood, make it rather viscid, and difficult to 
move in the vessels. The shrunken condition of the 
body, the low temperature, the muscular cramps, 
the anuria, are all consequences of the great loss of 
fluid from the vessels, and are partly, it may be, 
due to the action of the toxine, but the enormous dif- 
fusion from the veins is adequate to the production 
of these signs and symptoms. 

The return from the algid stage is a necessary 
reaction, if life continues. Secretion of the gastro- 
intestinal juices, of the bile and pancreatic fluid, and 
of the urine, must then take place, and convalescence 
be established. If the reaction is imperfect and too 
much damage has been done to the organs, there is 



64 CHOLERA. 

an incomplete resumption of function. This imper- 
fect performance of some necessary functions con- 
stitutes the morbid complexus known as the typhoid 
state. 

COURSE, DURATION AND TERMINATION. 

The limits of the prodromal stage of cholera — the 
period from the first infection to the beginning of 
objective symptoms — are by no means well estab- 
lished. It is usually stated as about three days. 
As the onset of symptoms means such development 
of the spirillum colonies as to cause irritation of the 
mucous rnembraue, there must be some variation in 
the time required in different subjects and under the 
changiug conditions in each. AH the circumstances 
that favor intestinal derangement promote the recep- 
tion and growth of the bacillus, aud vice versa. It is 
obviously difficult to fix upon any time. To say when 
the germ was swallowed, and when the first uneasi- 
ness was felt in the abdomen, is not possible, except 
in such experimental trials as those lately made in 
Vienna and Munich. Pettenkofer swallowed on 
October 7, 1892, one cubic centimetre of a fresh 
bouillon cholera culture ; on October 9th, or some 
forty-eight hours after taking the germs, he had the 
first symptoms of intestinal irritation — borborygmi 
and six to eight liquid motions. In Emmerich's 



COURSE, DURATION AND TERMINATION. 65 

case the incubation period was shorter, probably 
because the culture he took was only twenty-four 
hours old, whereas Pettenkofer's specimen had been 
received from Hamburg, and from this again cul- 
tures were made, thus reducing the toxic power of 
the spirillum. Emmerich swallowed the germs on 
October 17th, and the same night he had some 
irritation of the intestines and several liquid stools, 
which continuing, on the 18th and 19th he had char- 
acteristic rice-water discharges. In all, he passed 
twenty to thirty rice-water stools, and suffered from 
intense thirst, colic, prostration, and loss of voice. 1 

Hasserlik and four others in Strieker's Institute of 
Experimental Pathology, swallowed doses of comma 
bacilli. In from thirty-six hours to five days they 
experienced intestinal irritation in varying degree. 2 
These data show conclusively that the period of 
incubation varies, that if a given number of patients 
receive the poison at the same time, they will expe- 
rience symptoms at unequal periods. Therefore the 
period of incubation must be on a sliding scale, 
according to the state of individual susceptibility ; 
from twelve hours to three days it may be stated as 
a near approximation to the actual fact. 

At the first outbreak of an epidemic, the diarrhoeal 
stage is longer in duration for the first few cases 

i The Practitioner, March, 1893. 
2 The Lancet, March 4, 1893. 



66 CHOLERA. 

than it is subsequently, but this difference exists for 
a very brief period. The usual course of the diar- 
rheal stage is to get well or merge into the algid 
state in from six hours to twelve, to twenty-four 
hours, even to two or three days. The more rapidly 
the case develops the severer its type. The average 
duration of the preliminary diarrhoea known to be 
cholera diarrhoea, is twelve hours; of the so-called 
cholerine is twenty-four hours; of the algid stage is 
three to six hours. Convalescence sets in from 
twelve hours to four days after the first manifesta- 
tions. The typhoid stage lasts from five days to two 
weeks. 

In every important epidemic not a few cases occur 
at the outset in which the patients are stricken down 
without any preliminary diarrhoea or other pro- 
dromes. Eeiche notes this of the Hamburg epi- 
demic. " In a majority of cases the disease set in 
abruptly, and at once assumed its full intensity, so 
that frequently, and particularly at the beginning of 
the epidemic, profound collapse, with diarrhoea and 
cramps in the calves of the legs, speedily followed 
the initial vomiting. Cases of fulminant cholera 
sicca were common at this time." 1 At Havre 2 the 
same violence in the action of the cholera poison 
was manifest, a large number passing at once into 

1 Cholera in Hamburg, supra. 

2 Bull, de 1'Acadeuiie deMed , October. 1892. 



COURSE, DURATION AND TERMINATION. 67 

collapse without the preliminary diarrhoea and 
vomiting. 

The mortality from cholera is affected by so many 
circumstances that no proper estimate can be made 
without taking them into account. To compare 
results in one place with those of another place 
without noting the influences which in one place 
lessened and in another increased the death-rate 
would be most unjust and misleading. Of the first 
50 cases received into the two hospitals at Havre, 
48 died. In one of these hospitals known to be 
badly managed, there were 36 deaths in 57 cases, but 
taking 604 cases of admission for cholera to the two 
hospitals, there were 204 deaths, or one-third (33 
per cent.) died. During the epidemic in New York 
last fall (1892) there were 11 cases, which had no 
known connection with each other or with the cases 
at the quarantine station, or on the infected vessels, 
and occurred at widely separated points, and two 
only recovered, and doubts exist as to the genuineness 
of these. At the quarantine station where all the 
cholera coming in the vessels from Hamburg, Havre, 
and other infected ports, were received and treated, 
the results were as follows : Of 72 cases, 8 of them 
slight, there were 20 deaths. According to Reiche 
the mortality at the New General Hospital was 
somewhat more than 50 per cent. At the Nietleben 
Asylum, which is near Halle, the number of cases 



68 CHOLERA. 

up to the date of the report was 105, and of these 
36 proved fatal. At Nanterre, the combined hos- 
pital and prison, of the 51 cases that occurred, 49 
proved fatal. The total number of cases reported 
as having occurred in the Austrian Empire was 
214, and of these 125 died. During the cholera 
epidemic in Kashmir, there were 16,845 cases, and 
of these, 11,712 proved fatal. In the Lancet report 
on cholera in Russia, above quoted, it is stated that 
the total number of cases of cholera occurring in the 
Russian Empire from the beginning of the epidemic 
to December 1st was 555,010, and of these 267,880 
proved fatal. This last epidemic has proved to be 
more fatal than any that have preceded it. In 1831 
the mortality in Russia was 42.2 per cent., whereas 
in 1892 it was 45.8 per cent. As respects numbers 
and extent of territory invaded, the epidemic of 
1892 is the third in severity of the whole number of 
epidemics. 

The general average of the mortality in the epi- 
demics that have prevailed in this country was 50 
per cent. When the local hygienic condition was 
especially bad the proportion of deaths was high ; 
when fairly good the cases were much less severe, 
and the death-rate lower. The statistics of mor- 
tality in this country, as elsewhere, were much 
affected by the kind of cases included. Every case 
of diarrhoea was usually called cholera, and was 



DIAGNOSIS AND PROGNOSIS. 69 

taken up in the returns, when the epidemic pre- 
vailed. 

DIAGNOSIS AND PROGNOSIS. 

Until the discovery of the comma bacillus there 
was no means of differentiating with certainty, or 
indeed at all, between cholera and cholera nostras, 
or morbus. Now by a proper bacteriological exami- 
nation the diagnosis may be made with certainty and 
precision. During the present epidemic the views 
of Koch have been confirmed at all points. At 
Hamburg, at the Old and New General Hospitals, 
at Berlin, at the Moabit Hospital, and at Koch's 
Institute, the spirillum of cholera has been always 
discovered in the dejecta. Also, in Paris, where the 
extraordinary discovery of Koch was slow of recog- 
nition, the comma bacillus has been admitted to 
its true position as the cause of the cholera seizure, 
and its presence as essential to its diagnosis. 

The dejecta should be examined as soon as possible 
after being passed, and cover-glass preparations made 
of the rice-water matter. The arrangements necessary 
for the detection of the spirillum consist of a micro- 
scope provided with oil-immersion objectives, pre- 
ferably one-twelfth, one-fourth, and one-half inch, 
attached to a triple nose-piece, and with a stage 
arranged for an Abbe" condenser. A drop from an 



70 CHOLERA. 

ordinary cholera stool will contain much columnar 
epithelium, bacilli of various kinds, and other organ- 
isms, and if the examination is made without delay 
colonies of the comma bacilli may be seen. If there 
is much time lost, and especially if the contents of the 
canal are not examined until some time after death, 
the bacillus may not be found. Prof. Drasche stated 
in the course of a discussion before the Medical 
Society of Hamburg that in some fatal cases no 
bacilli were found, whilst in other instances they 
were still present twenty-three days after recovery 
had taken place. Dr. Dunham, of the Carnegie 
Laboratory, makes a similar statement. 

The direct examination of cholera matter, without 
preparation by cultures and staining, is never so 
satisfactory, whether the liquid stools themselves, 
or parts of clothing or bedding soiled with them, are 
examined. The material, whatever its nature, should 
be prepared in the form of plate cultures, and from 
these colonies transferred to other nutrient media, and 
the culture medium — gelatin, blood-serum, agar, or 
other medium — is made to solidify on glass plates, 
aud is then inoculated with the supposed germs. 
Planted in this soil and maintained at a proper tem- 
perature these organisms grow, producing their own 
kind. If the suspected matter is adherent to articles 
of clothing, bedding, etc., or to silk or cotton, or other 
fabrics, they are put in prepared bouillon, placed in 



DIAGNOSIS AND PKOGNOSIS. 71 

an incubator at a suitable heat, and this bouillon 
culture is transferred to plate cultures, and in turn 
to other cultures, so as to obtain typical forms 
for microscopical examination. By its manner of 
growth, its behavior in the various nutrient media, 
its need for or disinclination to oxygen, the mode in 
which it takes the stain, and its morphological uni- 
formity, we are to recognize the germ in question. 

The original dicta of Koch regarding the determi- 
nation of the nature of any given micro-organism 
still remain unimpeachable. That can be pronounced 
a true germ only if on cultivation it produces its own 
kind; if it is always found in the bodies of those 
dead with the disease ; if such organism can be grown 
in artificial media, and the cultures thus obtained 
will cause the same disease in the inferior animals 
when inoculated therewith. The only animals thus 
far shown to be susceptible to the peculiar action of 
the cholera germ are the mouse and the guinea- 
pig. If a culture is introduced into the intes- 
tinal canal directly, without passing through the 
stomach, the same changes are brought about as those 
made by cholera infection in man, except that there is 
no such vomiting or purging, but the animal speedily 
dies, with the usual symptoms of gastro-intestinal 
disturbance, and great numbers of bacilli are found 
swarming on the surface of the mucous membrane, 
penetrating the epithelium and villi, and entering the 



72 CHOLERA. 

follicles. As the cholera germ can only fructify in 
alkaline media, and is destroyed by the acid gastric 
juice, this explains why it can be swallowed almost 
with entire immunity in the normal state. But when 
the gastric juice is neutralized by the taking of an 
alkali, the swallowing of the germs must give rise to 
characteristic phenomena such as were noted especially 
in the case of Prof. Emmerich. In a perfectly normal 
state we may suppose that the germs find conditions 
not altogether favorable, in fact rather hostile, in the 
intestinal canal. It seems probable, indeed, that there 
must be some preparation made for the reception and 
growth of the germ, and that the absence of such 
arrangements neutralizes the efforts of the parasite 
to establish itself. From favorable to restraining 
conditions there are many gradations, and hence the 
occurrence of mild or severe cases, of the simplest 
diarrhcea or of the fulminant form causing death in 
a few hours. 

The prognosis of cholera is necessarily grave. The 
number of bacilli present is not conclusive, for as we 
have already seen, the patient may be in extremis 
and yet few bacilli be found. The prognosis may be 
favorable when the diarrhoea is the only symptom, 
but when nausea and vomiting occur and the dis- 
charges are of the rice-water kind, and especially 
when cramps come on, and circulation fails, only the 
most gloomy prognostication is reasonable. From the 



DIAGNOSIS AND PROGNOSIS. 73 

algid stage few emerge alive. It is necessary to be 
on one's guard when the vomiting and purging cease 
— the patient's condition is not otherwise improved, 
for this may signify the onset of coma. If the urine 
is secreted again, and especially if this is coincident 
with a reappearance of bile in the evacuations, the 
outlook is hopeful ; but an insufficient secretion is 
significant of a protracted convalescence, and, it may 
be, a fatal result at last. 



CHAPTER V. 

THE TREATMENT OF CHOLERA. 

Prevention.— Vaccination; Quarantine; Personal and 

Municipal Hygiene, etc. 

Treatment.— Medicinal; Enleroclym ; Venous Transfu- 
sion; Hypodermatoctysis, etc. 

Until the discovery of the spirillum of cholera, 
there had been no basis of a scientific character for the 
treatment of this disease. The empirical methods 
made use of in former epidemics proved singularly 
unfruitful in curative results. During the present 
epidemic, new remedies, applied in accordance with a 
more exact and truer conception of the therapeutical 
diagnosis, have been employed. It is only less im- 
portant to note the failures than to apply new reme- 
dies with a more just conception of their powers. 

If therapy has accomplished little, sanitation has 
done much. If the mortality rate continues at nearly 
the same level, it is certain that the epidemic influ- 
ence has declined considerably in force, and that the 
number and severity of the cases in communities and 
individuals are constantly lessening as compared with 
former experiences. Since to prevent a disease occur- 



PREVENTION. 75 

ring is much better than to cure it after it has ap- 
peared, in the management of a cholera epidemic it 
were far more desirable in every aspect to stop its 
progress than to experiment with remedies against 
individual eases. During the present epidemic there 
have been two striking object lessons showing the 
value of local and domestic sanitation, and of quar- 
antine. The first is the instance of London, where 
the authorities relied on cleanliness and disinfection ; 
the second is the case of New York, where an effi- 
cient quarantine was maintained, and but eleven cases 
— two of these doubtful — occurred in the city, and 
at points distant from each other and not communi- 
cating by persons or things. As the harbor of New 
York was in constant communication with Hamburg, 
Bremen, Havre, Paris, and other infected places, the 
success of the quarantine arrangements can hardly be 
doubted. London, whilst much nearer to the sources 
of infection than New York 'and unprotected by 
quarantine, escaped nearly as well, and no epidemic 
of cholera made its appearance there. 

The management of cholera includes prevention as 
well as therapy. I purpose to consider first those 
agencies employed to keep out cholera, or to destroy 
its germs should they obtain a foothold — all the 
measures of an enlightened private and public 
hygiene. 

Public sanitation ; quarantine ; sanitary cordons, 



7G CHOLERA. 

and the hygiene of the individual, are all concerned 
in this aspect of the treatment required in cholera 
epidemics. Since it has been established that cholera 
follows the routes of commerce and travels no faster 
than men proceed by the ordinary channels of com- 
munication, it has become evident that restriction 
in the commerce of infected peoples is necessary 
when an epidemic of cholera is on the march. At 
those points whence the epidemic influence starts, pre- 
cautionary measures should be instituted. Certain 
places in India and Arabia being natural homes of 
the cholera germ, should be so thoroughly treated as 
to exterminate the poison at its source, or these places 
should be so surrounded by sanitary cordons that the 
infection would be restrained within them, and here 
the final efforts to destroy the pathogenic micro- 
organisms should be made. The disease should be 
stamped out at its home. 

Quarantine. — No doubt should now be enter- 
tained of the efficiency of a proper quarantine in 
arresting the spread of cholera. It is not only the 
individual but his belongings that must be stopped ; 
not only the persons and personal effects from an in- 
fected district, but goods of various kinds, especially 
rags coming from cities the seat of epidemic influence. 
Paper money must be included amongst such belong- 
ings. To stop communication from an infected area, 
absolutely, is the most certain kind of quarantine 



PREVENTION. 77 

that can be instituted. As the necessities of com- 
merce will not permit such a measure as complete 
isolation, less efficient and partial quarantine must be 
substituted. Detention till the period of incubation 
be passed, disinfection of clothing and effects, and 
the most rigorous application of all the rules of per- 
sonal hygiene are the measures of quarantine to be 
made use of As for the most part quarantine is 
established on the sea-coast, at the ports of entry, 
inspection of vessels is an important duty. With any 
evidences of cholera existing on board of an emi- 
grant or passenger ship, the crew and passengers 
should be disembarked, the sick separated from the 
healthy, and all parts of the ship, the hold, store- 
rooms, steerage quarters, cabins, staterooms, etc., should 
be thoroughly disinfected with superheated steam, or, 
what late experiments have shown to be better, hot 
dry air, and the articles and clothing about the per- 
son of the sick should be burned. Clothing and 
goods can be treated most effectively by exposure to 
a hot dry air, which Dr. Sternberg J has shown to be 
more useful and less hurtful to fabrics and silks than 
steam. The direct sunlight is destructive of germs, 
and hence clothing and bedding hung up in the sun- 
shine alone, are presently freed from the cholera 
spirillum. In the course of an experimental research 

1 The Practitioner, London, March, 1893, p. 227. 



78 CHOLERA. 

to ascertain the effect of desiccation, Sternberg found 
it to be effective, and that " free exposure to fresh 
air and sunshine is one of the most reliable methods 
of disinfecting articles which have attached to them 
this cholera spirillum." The " thermal death-point " 
<>f the cholera germ in a moist state is about 130° F. 
and not more than ten minutes' exposure is required. 
If the moisture from the application of steam heat 
remains in the goods, any germs that escaped destruc- 
tion will be kept in a viable state. This is a serious 
objection to the use of superheated steam. It were 
better to subject all articles in contact with cholera 
patients to the action of dry air at a temperature of 
80° to 100° C, in a suitable chamber or drying 
oven. The articles must be carefully separated so 
that the hot air can come into actual contact with 
every piece. 

It was the conclusion of the International Sanitary 
Conference at Rome, that " disinfection of merchan- 
dise and of the mails is unnecessary." Koch main- 
tains the same ground, and Sternberg is also of this 
opinion. Now Uffelmann 1 finds that the spirillum 
remains active and capable of reproduction, on the 
printed page, seventeen hours, and on writing-paper 
enclosed in an envelope, twenty-four hours. Woollen 
and cotton goods, contained in the original packages, 

1 Berliner klinische Wochenschrift, No. 48, 1892. 



PREVENTION. 79 

are not dangerous if tbey have simply passed through 
an infected port, and they do not require disinfection. 
Such articles of merchandise as hides, especially in 
the green state ; fish, furs, and especially rags, re- 
quire careful disinfection, if they have been exposed 
to infection at any point in transit. Sternberg con- 
siders "the washing of the exterior of packages of 
merchandise with a solution of mercuric chloride, 
and the fumigation of the mails with sulphur diox- 
ide," au "unnecessary procedure, unless the mer- 
chandise has been exposed to infection by the dejecta 
of cholera patients during the voyage or after its 
arrival at our ports." 

As regards the individual, all exposed to infection, 
as when cholera has appeared on shipboard, should 
be bathed, their personal effects and clothing disin- 
fected, and they should be carefully separated from 
the sick and the convalescent. The bedding and 
clothing intended to be burned, should be well treated 
with a solution of corrosive sublimate 1 : 500, or of 
zinc chloride 1 : 100 before being put in the furnace. 
Passengers arriving at New York quarantine and 
Americans passing the sanitary cordons on the Con- 
tinent of Europe, complained loudly of the injury 
done to their effects by the disinfection. Silks, laces, 
and fine fabrics generally, were so damaged as to be 
unfit for use again. Some of the injury done is 
mechanical, but the superheated steam, the solutions 



80 CHOLERA. 

of sublimate and of zinc chloride, the gases, sulphur- 
ous acid, chlorine, etc., are very destructive of fine 
clothing, laces, silks, etc., as well as of germs. Sul- 
phurous acid forms colorless soluble sulphites, which 
leave the fabric decolorized aud its texture injured. 
Chlorine gas is very hurtful to the respiratory organs 
aud is apt to cause croupous pueumonia, but it is a 
powerful oxidizing germicide. Either sulphurous 
acid gas or chlorine gas is sufficiently powerful to 
destroy the spirillum of cholera, and the method of 
procedure is simple and the cost trifling. In the one 
case to burn sulphur on a pan of coals, in the other 
to act on chlorinated lime with hydrochloric acid, suf- 
fice to develop the gases in a few minutes. An ex- 
posure of a few hours of the infected clothing hung 
up in a tightly closed apartment will destroy all in- 
fectious matter. 

Quarantine on land, at the border of States, is 
carried on by means of a sanitary cordon with a cen- 
tral station, aud outlying pickets and inspectors 
placed on the roadways aud at railway stations to 
overhaul all persons and things going from an infected 
district into one free from the epidemic influence. At 
the central station are placed the appliances for in- 
spection and disinfection of persons and things. On 
the Continent of Europe, when cholera is prevailing 
in some special locality, the sanitary cordon is estab- 
lished at those places where the railway lines cross 



PREVENTION. 81 

the frontiers. In some few instances in this country 
where the yellow fever has threatened a given locality, 
such sanitary cordons have been established, but 
with little success. 

The German Government has issued instructions 
about disinfection, of which the following is an ab- 
stract. The disinfectants are " milk of lime," one 
part of lime to four of water ; chloride of lime ; 3 
per cent, solution of potash soap ; solution of car- 
bolic acid — the liquefied acid made so by the addition 
of 5 per cent, of water ; steam under pressure of not 
less than a tenth of an atmosphere ; boiling water. 
The articles to be disinfected to be boiled at least a 
half-hour. 

The liquid discharges to be received as far as pos- 
sible in vessels mixed with an equal volume of milk 
of lime and allowed to remain in contact at least one 
hour. Chloride of lime may be used, two heaping 
tablespoonfuls of the powder to each half-litre (one 
pint). Only fifteen minutes are required. 

The hands and other parts of the body coming in 
contact with infected articles, with the discharges, 
soiled clothes, etc., must be disinfected each time by 
thorough washing with solution of chloride of lime, 
or of carbolic acid. 

Bed and body linen and other articles of clothing 
which may be washed, should be put in receptacles 
with disinfectants immediately on being soiled. 



82 CHOLERA. 

Either the solution of soap or of carbolic acid may 
be used. Iu the former they should remain at least 
twenty-four hours, in the latter, at least twelve hours 
before being rinsed and further cleaned. 

Clothing that cannot be washed may be disinfected 
by steam. Leather articles may be wiped with car- 
bolic acid or chloride of lime solution. 

Wooden and metallic parts of furniture and simi- 
lar articles should be carefully and repeatedly rubbed 
with cloths with carbolic or potash soap solution. 
The floors of sick-rooms should be treated in the 
same way. The rags used should be burned. Floors 
can also be disinfected by milk of lime, which may 
be washed off after two hours of contact. 

Walls and woodwork may be whitewashed. After 
disinfection the rooms should be left unoccupied and 
well aired. 

The ground, pavement, and gutters fouled by 
cholera discharges, or in which suspicious waste runs, 
can be disinfected by copious flooding with milk of 
lime. 

In privies a litre (one quart) of milk of lime should 
be poured daily down each seat opening. The seats 
should be washed with the potash soap solution. 

At the Quarantine Station, New York, the follow- 
ing method of disinfection was carried out : 

The immigrants were first well rubbed with a 
bountiful supply of green soap, and then bathed. 



PREVENTION. 83 

The bath-tub consisted of a sail suspended at the 
four corners, the water constantly running. The 
crew's quarters and the steerage were scrubbed and 
washed out with a solution of corrosive sublimate 
1 : 500. The baggage and clothing were disinfected 
by sulphurous acid gas (burning sulphur), super- 
heated steam, and, where injury would not be done, 
by corrosive sublimate solution. Soiled clothing and 
bedding were wrapped in sheets wetted in corrosive 
sublimate solution and burned in the furnaces. 1 

During an epidemic of cholera, the condition of 
every individual becomes a matter of grave impor- 
tance. Just as filth, improper food, and dissipated 
habits invite the germs, so an opposite state prevents 
their lodgment. Especially is it necessary for those 
about the sick, nurses, attendants, and physicians, to 
avoid becoming conveyers of the poison, by the 
utmost cleanliness of the person, by putting aside all 
clothing worn whilst with the sick, and by avoiding 
contact with the cholera matter at any point. The 
physician, on leaving a cholera patient, should care- 
fully wash his hands with soap and water and use 
his nail-brush thoroughly, and also immerse his 
hands in a corrosive sublimate solution 1 : 500. 
Nurses and attendants on the sick should, besides 
washing the hands as above suggested, have a bath 

i The Cholera of 1892 in New York. By Reynold W. Wilcox, M.D., 
LL.D. 



84 CHOLERA. 

and fumigate their clothing and effects in sulphurous 
acid or chlorine gases. 

As the chief source of contamination — the chief 
carrier of contagion— is drinking-water, only water 
that has been boiled should be allowed. When there 
is hot water laid on, it suffices to use the water of the 
hot-water tap — for in that case the water is boiled in 
passing through the water-back of the range — and 
boiled, too, under the pressure of steam. It is far 
safer to make use of artificial ice during the existence 
of a cholera epidemic, for the natural ice is too often 
cut from superficial ponds of surface water, and the 
cholera germs, although inhibited at the freezing tem- 
perature, recover their vitality at the thawing. The 
river water is often rejected for the water of springs, 
when cholera is prevalent, but unwisely so, for the 
springs are readily enough contaminated through the 
ground-water. Fermented drinks — beer, ale, etc. — 
wine and spirits should be avoided, especially by 
those who are unaccustomed to their use. Brandy is 
consumed by the timid to keep up the vital powers, 
and some special kind of liquor is apt to be decided 
on as peculiarly fitted for the emergency, and drunk 
in amazing quantity. Such conduct only invites 
seizures. Indigestible food, badly cooked vegetables, 
unripe fruits, are partaken of by the ignorant and the 
careless, and many persons who always indulged in a 
full diet, eating everything, now restrict themselves 



PREVENTION. 85 

to a few articles, meat chiefly, avoiding vegetables 
and fruit. Changes of this kind are as injurious 
almost as excessive indulgence. Extremes in diet, 
and bad quality of food, are hurtful by setting up a 
catarrhal process in the small intestine, and this in 
turn favors the reception of the spirillum of cholera 
by inducing alkaline fermentation and thus increas- 
ing the alkalinity of the intestinal contents. 

Should a case of cholera occur in any given locality, 
measures should be at once instituted to " stamp out " 
the infection. If feasible, the dead should be cre- 
mated, and all articles of clothing and bedding em- 
ployed about the sick should be burned, or treated 
with disinfectants and by desiccation according to 
the methods already set forth. The rooms, the walls, 
the floors should be washed down with the disinfect- 
ant solutions; the gases, sulphurous acid and chlorine, 
should be disengaged in the rooms the sick occupied, 
and before being inhabited again they should be 
opened as freely as possible to the external air for 
several days. The methods of disinfection and of 
" stamping out " advised by the Prussian Govern- 
ment can be made use of, if desired, and they are at 
the same time cheap and efficient. Also, the method 
employed at quarantine, New York harhor, may be 
applied to the local circumstances of an outbreak at 
any interior point when cases and deaths announce its 
miner. 



86 CHOLERA. 

Cholera Vaccine. — A method of prevention, 
entirely new as respects its application to cholera, is 
Haffkine's vaccination, 1 but the way had been pre- 
pared for it, not only as respects the vaccinia of 
smallpox, but in the virus attenuations of Koch for 
producing tuberculin, and in Pasteur's attenuation of 
hydrophobia virus. 

According to Haffkine, microbial infections are 
of two kinds : Septicaemias and Intoxications. The 
septicaemia is caused by the development of the mi- 
crobe in the blood ; the intoxication is due to the 
absorption of a product of the life-growth of the 
microbe from its point of activity in the body. 
Cholera is one of the intoxications — that is, it is due 
to the absorption of a ptomaine produced by the bacil- 
lus, and absorbed from the intestinal canal. The 
comma bacillus cannot exist in the blood, or in the 
tissues of the body at any point, except on the sur- 
face of the intestinal mucous membrane, or deeper 
when ulcerations exist to afford the necessary outlet. 
In Haffkine's system there are two strengths of the 
cholera virus : an attenuated virus, and an exalted 
virus. The exalted virus is obtained by inoculating 
the peritoneum in a succession of rabbits each with 
the fluid drawn from the preceding rabbit. The 

' The British Medical Journal, February 4, 1893, " Haffkine's Method 
of Vaccination Against Asiatic Cholera," by E. A. Wright, M.D., and 
Surgeon-Captain D. Bruce, M.D. 



CHOLERA VACCINE. 87 

" vaccines " are two : 1. An emulsion of colonies of 
bacilli cultivated on agar — living vaccine ; 2. Carbol- 
ized, which is the same as No. 1, except made in a 5 
per cent, solution of carbolic acid, and containing no 
living bacteria. The vaccines are injected hypoder- 
matically. It may well be questioned here how far 
the bacilli and how far the peritoneal fluid are active 
in the production of the resulting phenomena. It 
was known twenty years ago that the peritoneum 
developed a highly toxic liquid when excited to in- 
flammation by the invasion of foreign matters, infec- 
tious or not, and that the poisonous character of the 
fluid obtained was greatly intensified by successive 
inoculations of the cavity with the resulting liquid 
from each preceding. 

As a prophylactic measure it has been proposed 
recently to inject subcutaueously the serum of the 
blood of cholera subjects. It is well known that 
normal blood serum is antagonistic to pathogenic or- 
ganisms. The use of the serum from the blood of 
cholera subjects is a measure of prevention, as it 
renders the individual thus inoculated immune to the 
cholera poison. Such is the theory, and in Russia 
many hundreds have already been subjected to the 
treatment, with alleged success. So many persons 
escape from an attack, even when an epidemic is most 
active, that such a mode of protection must remain 
in doubt. On the other hand, if an inoculated sub- 



88 CHOLERA. 

ject be attacked, the method is at once discredited. 
If it prove effective, the result must be due, not to 
the spirillum itself, but to a toxine produced by it — 
for, as now known, this organism is found ouly in the 
intestinal canal and never in the blood. 

The Medicinal Treatment of Cholera. — As 
the first distinct evidence of the presence of cholera 
is the occurrence of diarrhoea, so this symptom is of 
the first importance from the point of view of the 
treatment. The morbid complex demanding the 
application of remedies is the following : a watery 
diarrhoea ; an excessive alkalinity of the intestinal 
juices ; beginning detachment of the epithelium, and 
the growth of a micro-organism on the surface of .the 
mucosa. As we have to deal with a foreign body in 
a process of change, producing a colloidal substance 
of active toxic power, the question of elimination 
rises into importance. It seems to be an eminently 
rational procedure to attempt to rid the intestinal 
canal of the spirillum, the growth and development 
of which gives rise to the disturbance. It is sought 
to accomplish this by the use of eliminants. Al- 
though not the first to have suggested this practice, 
Dr. George Johnson, of London, has been its most 
persistent and able advocate for a quarter of a 
century — during the epidemic of 1866 and since. 
Condemning opium and astringents, his notion was 
to secure complete elimination from the intestinal 



TREATMENT. 89 

canal by the exhibition of an ounce or two of castor 
oil before endeavoring to stop the diarrhoea. Since 
the discovery of the comma bacillus, this method 
wears a rational aspect and has been carried out 
elsewhere in a modified form. In Russia, according 
to the method of Vachovitch, 1 calomel is given and 
followed by castor oil emulsion, with which is com- 
bined naphthalin. In such a combination, with the 
eliminant action of the castor oil is associated the 
germicide powers of calomel and naphthalin. The 
cholera subject under ordinary circumstances is unable 
to retain castor oil, and, hence, any utility it may 
have is confined to the first onset of the diarrhoea, 
when less unpleasant remedies will prove effective. 

Unquestionably the first remedy for the treatment 
of cholera diarrhoea is a mineral acid, or, as the 
French school prefer, lactic acid. I have seen more 
good accomplished by the exhibition of aromatic 
sulphuric acid with some opium than by any other 
remedies. 

B. — Acid, sulphuric, aromat. . . 4. = 3j. 

Tinct. opii deodorat. . . 2. = £ss. — M. 

S. — From ten to twenty drops every half-hour, hour, or 
longer as required, in some cold water. 

Dilute sulphuric acid may be substituted for the 

i Bull. gen. deTherap., February 15, 1893, p. 143. 



00 CHOLERA. 

aromatic, and for the deodorized tincture, the cam- 
phorated tincture of opium. 

R. — Acid, sulphuric, dil 16. 

Tinct. opii camph 32. — M. 

S. — A teaspoonful in some cold water every half-hour as 
required, or more or less frequently. 

Some advantages, as containing benzoic acid and oil 
of aniseed, are possessed by paregoric over the deodor- 
ized tincture, and it may be substituted. In Paris, 
lactic acid was much used. The following is the 
formula of Dujardin-Beaumetz ■} 

R. — Lactic acid 10. 

Syrup 20. 

Tincture of citron .... 2. 

Water 1000.— M. 

S. — Three spoonfuls every quarter of an hour. 
With this was often given twenty drops of paregoric. 

In former epidemics Hope's mixture, consisting of 
nitric acid with some nitrous, tincture of opium, 
and camphor water, was much relied on for the 
preliminary diarrhoea. At New York quarantine all 
suspected cases were made to drink " hydrochloric 
acid lemonade" 1:1000, and in some cases the 
same solution was used to irrigate the stomach. 
This practice was advocated by Professor Hayem 
especially. MM. Mendel and Simon 2 recommend 

1 Bull gen. de Therap., December 30, 1892. 2 Ibid. 



TREATMENT. 91 

for the cholera diarrhoea hydrochloric acid with 
cocaine and some tincture of opium, as follows : 

R. — Acid, hydrochloric. ... 2. 

Cocaine hydrochlorat. . . . 0.12. 

Tincture of opium ... 2. 

Distilled water .... 170. 

Syrup 200. — M. 

S. — A teaspoonful every two hours. 

The vegetable acids, tannic and gallic, were also 
given in pill form, variously combined, in former 
epidemics. Tannin, opium, and acetate of lead, with 
or without capsicum, were much employed. For 
example: . 



R. — Acid, tannici ] 
Plumbi acetat. ) 




. aa gr. xij. 


Opii 




• gr- ij- 


Oleoresinae capsici 




. . gr. iij.— M. 


Ft. pil. no. xij. 






S. — One pill every hour, 


or 


every two, three, or four 


hours. 







Tannic acid was also often given in combination 
with camphor and opium for the preliminary diar- 
rhoea — thus : 



R. — Acid, tannic. 


■ Bj. 


Camphorse .... 


. gr. x. 


Opii 


. gr. ij— M 


Ft. pil. no. xx. 




S. — One pill every hour or two. 





92 CHOLERA. 

Before quitting the subject of the acids in the 
treatment of cholera, I should not fail to mention the 
suggestion, said to have come from America, of 
injecting sulphuric acid subcutaneously : 

R— Acid, sulphuric, dil. 1.35 Gm. = n\,xx. 

Morphinse . . 0.01 Gm. = £ gr. 

Distilled water . 14. Gm. = fgss.— M. 
S. — For one injection. 

Lauenstein, of Hamburg, tried this, but was forced 
to give it up because it caused colossal gangrene. 
That such an injection would cause abscesses and 
sloughing can hardly be doubted by anyone familiar 
with the effects of acid solutions thrown under the 
skin. 

A great many astringent combinations were for- 
merly prescribed — astringent and anodyne. Camphor 
entered largely into these, and in the form of Ilubiui's 
solution — a saturated solution in pure alcohol — it 
was greatly used alone, especially by homoeopathic 
practitioners. It is difficult of administration, 
because the alcohol quickly evaporates, leaving the 
solid camphor on the tongue. I have known of an 
instance in which it was said the death of a homoeo- 
pathic doctor was caused by a heavy deposit of cam- 
phor in the throat, to whom Rubini's solution was 
given rapidly, in the algid stage. Camphor, bismuth, 
acetate of lead, and opium were frequently prescribed 






R . — Bismuthi subnitrat. 


• • 3ij. 


Plumbi acetat. 


. gr. xij 


Oamphorae 


• gr. vj. 


Oleoresinse capsici . 


• gr. iij.- 


Ft. pulv. no. xij. 




S. — One every hour or two. 





TREATMENT. 93 

together for the diarrhoea in the last epidemics before 
the present, The oleoresin of tannin entered into 
such combinations to obviate the coldness and depres- 
sion of the approaching algid stage. For example : 



-M. 



In India, chlorodyne has had the first place as a 
remedy for cholera since it was originally proposed 
by Dr. J. Collis Browne, of the Indian Army, not- 
withstanding it is a proprietary remedy and the exact 
composition unknown. Many imitations of it have 
appeared from time to time, some of them very close, 
but not one of them having precisely the same 
ingredients. The original chlorodyne contains mor- 
phine, atropine, cannabis indica extract, hydro- 
cyanic acid, glycerin, and treacle. Such a combina- 
tion is effective in the diarrhceal stage, but is relied 
on in every phase of the cholera seizure by the people 
of India, and the statistical results seem to be in its 
favor. When, however, stupor and the algid stage 
approach, opium or its alkaloid morphine becomes 
objectionable — less so, however, if the combination 
contains an agent which, like atropine and cannabis 



94 CHOLERA. 

indica, antagonizes the soporific and depressing effects 
of opium or morphine. With this, as in the use of 
opium in any form, it is necessary to avoid nar- 
cotism. The dose of chlorodyne ranges from five 
minims to twenty, repeated according to the state of 
the case. 

Almost any of the remedies above referred to may 
succeed in the arrest of the cholera diarrhoea if given 
timely, but when systemic infection occurs the 
remedies must possess different powers. Since the 
discovery of the comma bacillus in 1883 by Koch, 
various antiseptics have been resorted to in the 
expectation that the germs being destroyed the local 
and systemic conditions would subside. Amongst 
these are salol, creolin, naphthalin, naphthol, carbolic 
acid, creasote, salicylate of bismuth, arsenic, etc. 
The most confident expectations were entertained of 
the curative powers of salol. Composed as it is of 
salicylic acid and phenol, and decomposed into its 
constituents by an alkali, it was supposed that this 
reaction would occur in the small intestine and 
there the germs be destroyed. The first trials were 
reported on favorably, but presently it was found 
that these new remedies brought us no nearer to the 
cure than those long in use. Salol and creolin were 
tried freely in Hamburg (Keiche), in Berlin (Gutt- 
mann), and elsewhere, but were found useless. 
Naphthalin was used in some localities with marked 



TREATMENT. 95 

advantage, notably in Russia. Thus, E. Vachovitch 1 
gave it in wafers every half-hour, but he also 
administered calomel at the same time, and to this 
must be ascribed some of the undeniable benefit 
obtained. I myself have seen so much curative effect 
from the use of uaphthalin in diarrhoea that I cauuot 
doubt it must be efficacious iu cholera diarrhoea. As 
under its use the stools lose their characteristic odor — 
become odorless, in fact — it can hardly be doubtful 
that it acts on the micro-organisms infesting the canal. 
Naphthalin may be given with bismuth, creasote, or 
other disinfectants. Beta-naphthol is preferred by 
some, and, from the theoretical standpoint, it promises 
well. Iodoform 2 has been employed by Dr. Bujwid as 
a prophylactic when the cholera diarrhoea first mani- 
fests itself. In some experimental work Dr. Bujwid 
found iodoform to be exceedingly destructive to the 
comma bacillus, so small a proportion as 1 : 1000 
proving fatal in a minute. Iodoform may be given 
in a powder, or wafer, or packet with naphthalin 
and other antiseptics, as follows : 

R. — Iodoformi 9j. 

Naphthalin By. 

Bismuthi salicylat 3ij. — M. 

Ft. pulv. no. xx. 

S. — One every hour or two. 

i Vratch, No. 37, 1892. Quoted by the Bull. gen. de Therap., February 

2 Deutsche med. Zeitung, quoted in Centralblatt fur die gesammte 
Therapie. 



96 CHOLERA. 

Probably the best vehicle for such a powder is 
milk. It should be stirred up quickly and tossed off. 

An excellent remedy for the antiseptic treatment 
of cholera is arsenic. I am not sure that the 
arseniate of soda is not preferable to the arsenite of 
potassium. It is usual to combine some tincture of 
opium with the liquor sodii arseniatis or liquor 
potasii arsenitis, so the patient receives five to ten 
drops of the tincture of opium with one to two drops 
of the solution. 

Since the epidemic march of cholera began up to 
the present moment, calomel has occupied a large 
space iu the therapeutics of cholera — formerly as a 
remedy given to re-establish the biliary functions ; 
lately, as au intestinal disinfectant. Formerly it 
was held that calomel restores the secretions sus- 
pended by the cholera poison ; now it is supposed to 
exercise a germicidal power — to arrest the action of 
the bacillus and prevent the formation of the cholera 
toxine. In former epidemics calomel was given in 
3j to 5j doses to stop vomiting, and in smaller 
doses at shorter intervals when the object was to 
"change the secretions." There can be no doubt 
that calomel was more prized during former epi- 
demics of cholera than any other remedy. The 
present epidemic has not lessened — has rather in- 
creased, indeed, the repute in which it has been held. 
There is a marked unanimity in the reports from 



TREATMENT. 97 

Hamburg, Havre, Paris, Berlin, and other places 
where cholera has been prevailing. The mode of 
administration has been singularly alike in the 
various centres of infection : a single large dose at 
the outset — about eight grains — and smaller doses of 
one or two grains every half-hour, every hour, or 
two hours, until colored discharges occurred or fatal 
symptoms came on. Calomel was also added to the 
astringent and antiseptic combinations already given 
— in Russia, given with naphthalin ; in Paris, with 
bismuth, etc. 

The method of treatment entitled enterodysis, 
introduced by Cantani, is a novel expedient which 
has proved useful to some extent. It has been 
employed in all stages of the cholera seizure, and is 
extremely praised by Ziemssen for its constant 
utility at every period. There is, however, some 
difference of opinion respecting its real value as a 
remedy. The formula as proposed by Cantani is as 
follows : 



R . — Infusion of chamo 

mile . 

Tannic acid . 

Laudanum . 

Gum arabic . 



2 litres = 2 quarts. 

5 to 20 Gm. = Sjss-gj. 
20 to 30 drops. 
30 to 50 Gm. = 1 oz. to If oz. 



The process consists merely in irrigation of the 
bowels with a solution of tannic acid, and the 
simplest apparatus suffices — a fountain or Davidson's 



98 



CHOLERA. 



syringe serving perfectly well for this purpose 
(Fig. 7). To insure passage of the fluid beyond the 
sigmoid flexure a flexible rectal tube should be intro- 
duced and connected with the distal extremity of the 




A glass fountain syringe with the needle attached. 

syringe tube. The patient should lie on his back or 
right side with the knees well drawn up, and the 
abdomen should be gently kneaded to pass the fluid 
through the ileo-csecal valve. Differences of opinion 
exist as to the flow of fluid backward through the 



TREATMENT. 99 

valve. Certainly in the normal state it is difficult to 
effect this, if it be not impossible. The most recent 
experiments 1 undertaken to prove the permeability of 
the orifice have established it only in part. It was 
found in a series of seven trials to ascertain whether 
the fluid passed through the ileo-csecal valve, that 
in nearly one-half of the subjects the orifice re- 
mained closed and the fluid could not be forced 
through. These trials were made on cholera subjects. 
In the treatment of some cases by enteroclysis it was 
found that the tannin solution was in part rejected by 
vomiting. The evidence, therefore, is conclusive that 
the solution in many cases certainly can be made to 
pass through the ileo-csecal valve, notwithstanding the 
experimental trials which heretofore have seemed to 
prove the contrary. The utility of the tannin consists 
in the chemical action it is supposed to exert on the 
mucous membrane and on the comma bacillus, in 
checking the transudation from the vessels and in 
restraining the diarrhoea. It is a remedy to be 
employed especially during the diarrhceal stage, but, 
according to Ziemssen, it is useful at all stages of the 
disease. Rumpf, of Hamburg, has found it useless, 



1 Dr. Judson Daland, at Swinburne Island, New York Quarantine. 
He experimented on the bodies of children only : one, six years old ; the 
others, two years old. In two, the valve was competent to prevent irri- 
gation of the small intestine ; in one, a twist of the intestine prevented 
success, and in four the valve was passed without difficulty. Trans. Coll. 
of Phys. of Philadelphia, 1892, p. 210. 



100 CHOLERA. 

except before the stage of infection — the algid stage — 
and that seems to be the impression of many in 
regard to its real place in the treatment. 

Besides tannin, or in conjunction with it, various 
antiseptic solutions can be used by enteroclysis. A 
weak solution of corrosive chloride, 1 : 5000, or of 
carbolate of zinc 1 : 1000, or of silver nitrate 
1 : 1000, may be employed in this way. The mere 
douching of the bowel with hot water — as hot as can 
be borne — has had a good effect, increasing the 
warmth of the body, raising the heart-beat, and 
washing out the retained " rice-water" matters. 
Enemata of starch and laudanum were a good deal 
used in former epidemics. They have been employed 
sparingly in the present epidemic to restrain diar- 
rhoea. 

As respects the use of opium in cholera, the expe- 
rience of the present epidemic is remarkably uniform 
— that it is hurtful if employed freely even during 
the diarrhoeal stage, but still more so if the narcotic 
eifect is superadded to the stupor or coma of the algid 
stage. Reiche, Rumpf of Hamburg, Guttmann of 
Berlin, and Ziemssen oppose the use of opium in 
large doses, especially at the approach of, or during 
the algid stage, but favor its use for the relief of 
cramp, and to check the early diarrhoea. It is 
highly probable that the numerous remedies for the 
diarrhoea would avail little were this constituent 



TREATMENT. 101 

omitted from the formulae. In fact, it is necessary 
to an effective treatment of the cholera diarrhoea, but 
when the kidneys have ceased to functionate, and 
ursemic symptoms are manifest, and when the loss of 
serum has so damaged the red blood-globules that 
they cease to carry oxygen, the effects of opium only 
intensify these conditions. 

Almost any remedy or any of the combinations of 
remedies above mentioned will usually arrest the 
preliminary diarrhoea if given early enough, and 
before systemic infection occurs, and if the patient's 
condition is favorable. Nevertheless, in some cases, 
from the earliest beginning of symptoms no remedy 
seems equal to the arrest of the disease, and purging 
and vomiting go on despite the most diligent appli- 
cation of the most approved means ; in some, the 
algid stage is ushered in tempestuously after one or 
two discharges ; in others the patient is stricken down 
suddenly, profoundly intoxicated, but without diar- 
rhoea or vomiting, and the algid stage is at once fully 
developed. Ordinary remedies seem powerless under 
these circumstances. Whatever offers to be done 
must be carried out without delay. As the problem 
requiring immediate solution is the restoration of the 
fluidity of the blood, whereby the organs now in a 
state of suspended activity can be made to func- 
tionate, the first step is to supply the vascular system 
with the needful material. The loss is that of the 



102 CHOLERA. 

blood serum ; the supply must be of a material to 
take its place. So long ago as 1834 the disastrous 
effects of the diffusion from the bloodvessels were 
fully understood, aud the meaus of relief suggested. 
Iujection of fluid into the veins was naturally 
supposed to be the appropriate remedy, and the 
attempt was then made to arouse patients from the 
algid state by an intra-venous infusion of salines. 
This practice has been followed to some exteut in 
every epidemic since, but until the present, ill success 
has attended it ; the first marvellous resuscitation of 
the patient was not sustained, but he quickly lapsed 
again into the algid state and then expired. Im- 
provements have been made in the technique, so that 
now the little operation of infusion of salines can be 
performed more easily aud safely than formerly, and 
with a constantly improving ratio of recoveries. The 
apparatus required consists of a glass reservoir, a 
flexible tube, and a suitable needle canula for perfo- 
rating the vein (Fig. 8). The transfusion apparatus 
of Roussel, or any of the simpler kinds employed for 
blood transfusion may be utilized for this purpose ; 
but, on the whole, the simple fountain with its flexi- 
ble tube and perforated needle suffices. The whole 
apparatus must be sterilized by boiling in water, and 
the water used in making the solution must also be 
sterilized. The composition of the solution em- 
ployed varies a little, but no radical differences exist. 



TREATMENT. 103 

As a rule, it is merely a common salt solution, 
varied with sulphate or carbonate of soda, or the 
phosphate of sodium with the sulphate and chloride 
of sodium. 

Fig. 8. 




Apparatus for intra- venous infusion. 

The usual proportions are as follows : 

R. — Water, sterilized 

Sodium bicarbonate 
Sodium chloride 

Considerable variations as respects the amount 
infused at one time, as well as the ingredients, are to 



1000. 


*== 1 quart. 


1. 


= 15.5 grains. 


6. 


= 95 



104 CHOLERA. 

be noted. Some prefer the sulphate of sodium to the 
bicarbonate, and others the phosphate of sodium ; 
some add alcohol or brandy, others hydrogen diox- 
ide. Again, there is a general conviction that the 
salt solution, alone, suffices. The temperature of the 
fluid should be from 100° F. to 104° F., usually at 
the latter figure. The quantity of fluid thrown into 
the veins in cases at Hamburg, Paris, and Berlin, 
has been quite extraordinary — from one to two litres 
is advised, and as much as four litres — four quarts — 
have been given. The intra-venous iujections have 
been repeated in a half-hour, in an hour, or two 
to four hours, according to the effect of the preceding 
infusions. It is necessary to avoid the entrance of 
air, though experience and experiment have shown 
that the dangers of this accident have been much 
exaggerated. Foreign bodies, especially micro-organ- 
isms, should be vigorously excluded. The appa- 
ratus should be carefully sterilized in advance. A 
vein at the elbow, or the saphena vein, may be 
selected. Schede, 1 in a discussion before the Ham- 
burg Medical Society, strongly advocated the method 
of arterial transfusion of Landois, a small artery — 
the posterior tibial, for example — being selected for 
this purpose. 

Although the large amounts of fluid passed into 

1 Centralblatt fur die gesammte Therapie, December, 1893. 



TREATMENT. 105 

the veins were apparently beneficial, I am yet skepti- 
cal as to the real value of such heroic measures. It 
has been found that in the transfusion of blood to 
relieve the effects of hemorrhage, only a few ounces 
— not more than four — can be advantageously made 
use of, and that large quantities overwhelm the heart 
or seriously embarrass its movements. I fear that 
the sudden infusion of so much fluid in the vascular 
system only precipitates a return of the outward dif- 
fusion from the veins. So remarkable are the results 
of the saline infusion by litre in quantity, that only 
two operators seem to have tried the less brilliant pro- 
cedure of using a comparatively small dose. The 
immediate effects of the transfusion are striking: the 
cold, shrunken, voiceless and pulseless patient seems to 
pass from death to active life ; his warmth is restored, 
and the pulse reappears at the wrist ; his face and his 
sunken, glazed eye fill out again, and his strength so 
marvellously returns that he may be able to sit up 
and converse with those about him, or even walk 
about the room. In but a small proportion of cases, 
we shall find, are the results permanent. In a few 
minutes to three or four hours, the vomiting and 
purging come on again, and in a short time the algid 
state is resumed. A repetition of the saline infusion 
is followed by similar good effects, but they last a 
shorter time, and the collapse that follows increases 
in depth with each repetition of the operation. In a 



106 CHOLERA. 

small proportion of cases the improvement due to 
the saline infusion is maintained and the patient 
passes into prompt convalescence. 

Accidents from the intra-venous transfusion are 
uncommon. No abscesses, no thrombosis or em- 
bolism, no septicaemia, followed the operation at 
Hamburg. At the monieut of the passage of the 
fluid into the veins some giddiness, singing in the 
ears, and a sense of pressure within the cranium are 
experienced. An uncomfortable sense of tingling 
and burning is felt in the skin, and not unfre- 
quently a general outbreak of urticaria, or the larger 
and more voluminous wheals of erythema nodosum, 
appear on the surface. 

As regards the curative results, it must be admitted 
that they are not very striking, but at the same time 
the transfusion of salines is a distinct advance on 
former methods, and more may be expected of this 
treatment as experience grows. Lauensteiu, of Ham- 
burg, gives his results as follows : Of 173 cases, all 
of them grave, 54 were cured by infusions, and of 
this 54, 28 were treated by the intra-venous method. 
Of the city of Hamburg in general, Reiche reports 
the recoveries after intra-venous trausfusion as about 
25 per cent. It must be understood, however, 
that only in cases in the algid state w r as this pro- 
cedure resorted to. Although there are no exact data 
as to the proportion of recoveries from this stage of 



TREATMENT. 107 

the disease, it can hardly be doubted that the relative 
number is far greater by saline trausfusiou than in 
cases treated on other lines. 

The method of treatment by hypodermatoclysis is 
entirely modern — a creation of the existing epidemic, 
and, like euteroclysis, was the suggestion of Cantani. 
It is " hypodermatic infusion," and as such has long 
been kuowu and practised ; but as now utilized as 
hypodermatoclysis, it is so far a departure from the 
original procedure as to constitute a new method of 
therapy. It consists in the injection beneath the 
skin of a saline solution, instead of injecting it or 
transfusing into the veins. The solution of Cantani 
is the following : 

R.— Water, sterilized . 1000 Gm. = 11. = 1 qt. 
Salt ... 10 " = Sy'ss. 

Carbonate of sodium 5 " = 77 grs. 

Nothnagel made use of this formula : Sterilized 
water = 1 quart, in which are dissolved 6 grammes 
(93 grains) of carbonate of sodium and 8 grammes 
(120 grains) of common salt. Samuel, the author of 
the continuous method, favors a simple solution of 
common salt in sterilized water — 4 grammes (5j) to 
1 litre = quart, at 104° F. To the saline solution 
Rumpf added hydrogen dioxide, Heyse, alcohol, and 
others have made use of thymol, boric acid, and 
other antiseptics. There is no particular utility in 



108 CHOLERA. 

these additions, and one solution may be employed 
instead of another. 

The apparatus required is of the simplest char- 
acter : merely a reservoir, a flexible tube and the 
hypodermatic needle attached thereto. A fountain 
or a Davidson syringe serves the purpose perfectly 
well. The several parts of the apparatus must be 




A form of reservoir with pump to insure the passage of the fluid, 
used in Germany. 

carefully sterilized before using. The purpose to be 
accomplished is to introduce under the skin as large 
a quantity of the fluid as can be made to enter at each 
operation, every half-hour to every four hours. As 
the attempt is made to pass into the blood from one 
to four litres (one to four quarts), time is required to 
accomplish this, and hence the plan proposed by 



HYPODERMATOCLYSIS. 109 

Samuel and known by his name — " Samuel's con- 
tinuous method." By this method the needle re- 
mains in situ, and the fountaiu is so elevated as to 
permit the flow guttalim, so that the skiu be not so 
disteudecl at ouce as to stop the movement altogether. 
Gentle massage is usually advised to secure the dis- 
persion of the solution through the surrounding 
parts. Notwithstanding the utmost care be used, if 
the injection be carried on too long, or if it is re- 
peatedly performed in the same place, swelling and 
tenderness remain aud an abscess may be produced. 
It is said that dangerous difficulty of breathing, 
almost asphyxia, has been brought on by injecting 
the fluid in the loose tissue above the clavicle. There 
are other situations available where the subcutaneous 
tissue is abundant and the absorption active. If the 
continuous method be employed, the place selected 
should be as little sensitive as possible, and should be 
so situated as to be undisturbed by the movements of 
the members. Cceteris paribus, the buttocks, the 
flanks, the axillary regions, and the space beneath 
the axilla are to be preferred. 

As compared with intra- venous infusion of salines, 
hypodermatoclysis is far less quick in action, less 
powerful, and is safer. It must be said, however, 
that the danger of the intra-venous infusion or injec- 
tion is trifling. There should, indeed, be no danger, 
if proper care be used. An advantage possessed by 



110 CHOLERA. 

hypodermatoclysis is that no assistant is required ; it 
may be performed at once with the simplest means ; 
whereas in the practice of the intravenous method an 
assistant is necessary, and certain preparations must 
be made, before undertaking the operation at all. 
There are differences of opinion as to the therapeutic 
value of the two expedients. At Koch's Institute 
in Berlin intra-veuous transfusion is preferred; at the 
Moabit Hospital, Berlin, Guttmann made use of 
hypodermatoclysis by choice. In Paris, the most 
active operator, Galliard, practised the subcutaneous 
infusion in three hundred cases, and seems satisfied 
with the result. During the recent epidemic at Ham- 
burg, the hospital physicians, Hayse, Reiche, and 
Rumpf, employed both modes of saline infusion, but 
they prefer the intra-venous after an extended experi- 
ence, because the curative results are greater. In 
general practice in the city, the subcutaneous was 
more largely used, because more convenient and easy, 
no assistant being required. Mathieu, 1 who had con- 
siderable experience in the Paris epidemic, advises 
the subcutaneous infusion in the mild cases only, and 
he gives 200 to 600 grammes — only about one-half 
of that given by most of those who have been quoted. 
Siredey 2 injected Hayem's solution in the dose of 1 50 

1 Bull. gen. de Th6rapeutique, December, 1893. 

2 Ibid., p. 542. 



SUBCUTANEOUS INJECTION. Ill 

to 300 grammes, one-third only of that usually given, 
and of fifty-four serious cases, sixteen were cured. 
At New York quarantine they used the method of 
hypodermatoclysis only and with favorable results. 
All of the cases occurring in New York City, except 
two in which no bacteriological diagnosis was made, 
proved fatal ; but we have no particulars as to the 
remedies employed in these cases. 

The subcutaneous injection of sodium phosphate 
has lately been proposed as a substitute for the organic 
solutions — the testicular, the cerebral, and the cardiac, 
etc. — so strongly urged of late as remedies in low 
states of the system, and also in the algid stage of 
cholera. Dr. Crocq, 1 of Brussels, has lately come 
forward with this expedient — the subcutaneous injec- 
tion of sodium phosphate — as a substitute for these 
organic solutions on the ground that their utility is 
really due to the presence of the phosphates, and that 
the same end cau be attained by its administration 
subcutaneously. Luton, of Rheims, has lately also 
strongly advocated the sodium phosphate subcuta- 
neously as a remedy when there is depression of the 
vital powers — in neurasthenia, in the algid stage of 
cholera, etc. — and he claims priority in this practice. 
His formula is as follows : 



1 Bull. gen. de Therapeutique, March 30, 1893, p. 265. Les Injections 
Souscutanees de Phosphate de Soude, par M. Ed. Egasse. 



112 CHOLERA. 

R. — Sodium phosphate (cryst.) . . 5 parts. 

Sodium sulphate . . . . 10 " 

Water, distilled 100 *' 

Boil together and filter. 

The sulphate is added to give the necessary density. 
This forms a clear, colorless solution entirely free 
from irritating qualities. The effect of the injection 
is not decided. It causes no pain and the slight 
swelling disappears in an hour or two. The sys- 
temic effects consist in some fulness of the head, and 
a general sense of warmth and diffused feeling of 
comfort and well-being. As no danger can occur 
from its administration, this expedient deserves a trial 
in cholera and it should be used freely. 

When vomiting sets in actively and rice-water 
evacuations occur, the absorption of remedies by the 
stomach becomes most uncertain, with the probabili- 
ties against it. The rapid administration of reme- 
dies only adds to the distresses of the patient. Every 
one familiar with the care of cases of cholera knows 
how futile are the efforts to obtain results from the 
remedies ; they may be retained for a time, but pres- 
ently they come up with a loud explosive effort by 
regurgitation, and little, if any, is absorbed. The 
attempts to administer stimulants by the stomach are 
equally futile. Always with the failure of the vital 
powers, brandy and whiskey, champagne, and other 
stimulants are poured into the stomach ; but the cir- 



LAVAGE OF THE STOMACH. 113 

dilation does not revive under their use, and in a 
short time they are regurgitated in the form in which 
they were taken. There are two expedients to be re- 
sorted to under these circumstances : irrigation of the 
stomach and the hypodermatic injection of remedies. 

For lavage of the stomach a flexible oesophageal 
tube, a reservoir for containing the fluid, and a flexi- 
ble tube for connecting the reservoir with the stomach- 
tube are the necessary parts. A flexible stomach- 
tube with a funnel-shaped orifice is sufficient for the 
purpose, to reduce the matter to its simplest form. 
The tube will act as a siphon. In patients asphyx- 
iated, or insensible, or merely in a stupor, a stomach- 
tube must be introduced with care, the distal end 
being carried back to the posterior wall of the fauces 
to clear the glottis. It goes without saying that the 
apparatus should be carefully sterilized, and the 
water should be boiled in advance of the solution in 
it of acid, or of salines, or antiseptics. MM. Hayem 
and Lesage employed, with success, boiled water or 
hot water with boric acid in solution. They found 
that a single irrigation would sometimes arrest the 
vomiting ; but it was necessary usually to repeat the 
operation in six to eight hours. 

M. Delpech made use of a solution of lactic acid. 
It may have same strength as the boric acid solution : 

R. — Hot water . . 1000 grammes = 1 quart. 
Boric acid . . 4-8 '' = 3j-3ij. 



114 CHOLERA. 

Hay em, also, advocates irrigation with lactic acid 
solution. At the New York quarantine they made 
use of hydrochloric acid iu the proportion of 
1 : 1000, aud as the comparative mortality was low, 
I assume that this expedieut was a success. 

It has been seen when the stomach was washed out 
that the contents of the organ apart from that thrown 
in or medicines or foods administered, consisted of 
the characteristic rice-water matter, and relief was 
felt when the organ was rid of it. To wash out 
the stomach is almost as necessary a part of the 
elirainant plan of treatment as enteroclysis. Besides, 
when the stomach is well emptied, vomiting often 
stops and the organ is then in a far better condition 
to absorb medicines and stimulants. 

The hypodermatic method of administering reme- 
dies is a most important resource when the algid 
stage approaches, when the vomiting begins and 
everything is rejected as soon as swallowed, almost 
before it reaches the stomach. At the period of sys- 
temic infection, the only remedies that can oppose 
the action of the cholera toxine are such as corrosive 
sublimate aud Klebs's anticholerine. It is only 
within a few months that attempts have been made 
to obtain the curative power of corrosive sublimate 
over the cholera infection. The duration of a case is 
so short that the antiseptic action of sublimate has 
but little space in which to operate. The dose must 



KLEBS'S CHOLERA TOXINE. 115 

needs be small, but it can be administered with com- 
parative frequency : 

R. — Hydrarg. chlor. cor gr. j. 

Aquae destil. 3J. — M. 

S. — Twenty minims for the initial dose, and ten minims 
every half-hour or hour. 

Attempts have been made to reduce the power of 
the cholera toxine by successive cultures of the 
bacillus in or on various media. Thus far Klebs's 
anticholerine is the most opportune and successful 
product of the kind. Dr. Manchot 1 has made some 
trials of it in the Hamburg epidemic, and with results 
that promise well for future attempts. Of 31 cases 
treated with Klebs's anticholerine, 21 died, being a 
mortality rate of 67.7 per cent. If we compare this 
outcome with the method of transfusion of salines we 
find the result is greatly in favor of the anticholerine. 
Of 103 cases referred to by Manchot, which were 
treated by transfusion of salines, 87 died. The dif- 
ference in favor of the anticholerine is no less than 
16 per cent. It has been proposed recently to pre- 
pare an anticholerine by cultivating the comma 
bacillus with the juice of the thymus gland. Thus 
far it has not passed beyond the experimental 
stage. 

Various agents have been utilized hypodermati- 

1 Centralblatt fiir die gesammte Therapie, December, 1892. 



116 CHOLERA. 

cally in the present epidemic to maintain the circula- 
tion. Dr. Trussewitsch, of Russia, employed Avith 
signal advantage injections of amyl nitrite and of 
ammonia. Sometimes the amyl nitrite was simply 
dropped on the tongue, and nitroglycerin iujected. 
These agents act powerfully in raising up the heart- 
beat, by lowering the peripheral tension, thus per- 
mitting the circulation to be maintained with the 
minimum of effort on the part of the heart. Such 
au expedient is especially promising when by saline 
transfusion the blood has been prepared for active 
movement. Dr. Nedzwedzki 1 strongly advocates the 
subcutaneous injection of quinine, giving it in saline 
infusion. During the epidemic of 1876, in the south- 
west, atropine was quite largely used, alone and in 
combination with morphine, for the relief of the 
algid state. It has a specially good effect when saline 
intra-venous transfusion has preceded it. Under its 
action the pulse appears at the wrist, the skin be- 
comes warm and dry, and the voice assumes a more 
natural character. My own experience has been 
with the morphine combination, where the powers of 
atropine are somewhat modified. 

In Paris caffein was much used, and in combina- 
tion with benzoate of sodium, according to this for- 
mula : 

i St. I'etersburger med. Wochensclir., ls'.i_>, No. 37. Centralblatt fiir 
die gesammte Therapie, November, 1892. 



TREATMENT. 117 

1£.— Caffein . . . 2 grammes = 3ss. 
Benzoate of sodium 2 " 50 = 40 grs. 
Water . . q. s. 10 c.c. = about 2i drm. 

A syringeful — about 20 minims — would therefore con- 
tain nearly 5 grains of caffein. This can be repeated every 
two, three or four hours. 

At the Necker Hospital much confidence was felt 
in ether injections. A syringeful of ether can be 
given every fifteen minutes, or half-hour, and much 
relief is afforded by it to the muscular cramps. Co- 
caine has been found highly beneficial in the present 
epidemic. At Hopital Beaujon it was used with suc- 
cass to arrest the vomiting, and by Dr. Kohos — who 
found it, in doses of from five to ten centigrammes, 
to arrest the vomiting, to relieve the cramps, and to 
increase the circulation. For the relief of cramp, in 
my experience, no agent is equal to chloral. It must 
be given hypodermatically, five or ten grains at a 
dose, dissolved in sufficient sterilized water. It 
affords prompt relief to the cramps, and restores 
warmth to the surface, by increasing the circulation. 
The efficiency of chloral is promoted by the previous 
or simultaneous administration of morphine and atro- 
pine. I have seen this combination effect marvels in 
the algid stage of cholera. 

In my experience, the exhibition of alcoholic 
stimulants has been carried much too far. The thirst 
is excessive and the demand for drink constant, and 



118 CHOLERA. 

as the decline in the strength is rapid the temptation 
to supply the patient with stimulants is too great to 
be resisted. Who has not seen the drink swallowed 
with avidity brought up immediately, and the most 
potent of alcohol liquors taken in vain as regards any 
influence over the failure in the vital powers. The 
stimulants actually required should be injected sub- 
cutaneously, but deeply, into the loosest areolar tissue 
— from one to two drachms ; or some pure alcohol 
may be added to the saline solution given by intra- 
venous infusion or hypodermatoclysis. 

During the present epidemic warm baths have an 
unusual prominence in the treatment of the algid con- 
dition. Formerly, bottles of hot water, hot bricks, 
and hot flannels were applied as the surface grew cold. 
Now baths in temperature from 100° F. to 104° F. 
are made use of, not, of course, for hygienic reason, 
but to supply a much-needed warmth. Wiuternitz, 
who is a leading authority on the water treatment in 
Germany, advocates the sitz bath at a moderate 
warmth, with frictions of the body with a towel 
wrung out in the water of the bath. Immersion of 
the patient in water at 104° F., followed by wraps of 
flannel and blankets heated to 105° F. Siredey em- 
ployed baths at 98° to 101° F., for ten to fifteen 
minutes, afterward wrapping the body in cotton or 
gummed taffeta, and applied mustard plasters. 
Lesage used baths at 40° C. (= 104° F.) of water 



TREATMENT. 119 

only, or of water and mustard. For those com- 
pletely algid, the immersion of the body was persisted 
in for several hours. There are no data showing 
the influence of warm baths over the mortality rates 
of cholera, and I doubt whether they exercised any. 
As dry-heat is destructive of the comma bacillus, 
whenever practicable hot-air baths may be used. At 
Swinburne Island Hospital, New York Quarantine, 
the patients in the algid stage were placed near the 
hot-air radiators, so that they could receive the 
highest heat of the furnace (Daland). 

When the first colored matters appear in the stools, 
and the secretion of urine begins, when the pulse can 
be felt at the wrist, and the respiration grows in 
volume and depth, convalescence has probably entered 
on its tedious course, or these appearances may prove 
delusive, and a typhoid state, or the condition known 
as uraemia, may be developing. If the stomach will 
retain them, such diluents as cream of tartar, lemon- 
ade, wine- whey, skimmed milk, hot, may be allowed. 
Champagne is always grateful to these patients, and 
may be taken freely if it agrees. At this stage irri- 
gation of the intestine with salt solution is recom- 
mended by Siredey, and if the diarrhoea persists, 
Cantani's enteroclysis with tannin proves useful. If 
the urinary secretion does not come on, or fails to 
increase, and the coma deepens, pilocarpine should be 
administered — one-eighth of a grain to one-fifth. 



120 CHOLERA. 

This may be repeated once or twice in the twenty- 
four hours. According to Dr. Duke, 1 of the Bengal 
Army, its action is " marvellous aud rapid," thus 
confirming the observations of his colleague, Dr. 
Mullen, of the Bengal Army, who first suggested 
this use of pilocarpine. Not only when the urine is 
no longer secreted, but when the secretion is rapidly 
declining, is the period when the administration of 
this remedy should be begun. The curative power 
of pilocarpine is promoted by the simultaneous ad- 
ministration of strychnine, as has also been shown 
by Dr. Mullen, whose practice consists in giving five 
minims of liquor strychnia? (B. P.) which has the 
strength of one to one hundred and twenty, and 
is therefore equivalent to one twenty-fourth of a 
grain. After four to six hour, five minims are again 
injected, and was repeated up to fifteen or twenty 
minims in twenty-four hours. " The success of the 
remedy," says Dr. Day, " is known by the return of 
the pulse, frequently in twelve hours — and by the 
voice." Under the same conditions cocaine acts effi- 
ciently in bringing on the urinary secretion and in 
stopping the cramps which may still occur. From 
one-tenth to one-fifth of a grain is a sufficient dose, 
and this may be repeated every two, three, or four 
hours if the result of the first is favorable. When it 

1 Lancet, February 4, 1893, p. 244, 






TREATMENT. 121 

acts well, this fact is known by a reviving warmth 
of surface, by an increased diuresis, by return of the 
voice, and a distinct gain in muscular power. 

As caffeine has active diuretic property, this may 
also be given to stimulate the renal function, either 
alone or in solution with benzoate of sodium. Also 
digitalin is an appropriate remedy to promote action 
of the kidneys, or the tincture of digitalis, may be 
administered in the same way. Quinine is an effi- 
cient agent at this stage — the typhoid state — especially 
when the reaction runs over into the febrile, and the 
patient wears the usual aspect of one in the lowest 
stage of the fever. Dr. Nedzwedzki, of St. Peters- 
burg, likens the algid stage of cholera to a pernicious 
intermittent, and for this reason strongly urges the 
administration of quinine. His formula is as fol- 
lows : 

• R. — Hydrochlorate of quinine . . .30. 

Water 100. 

Common salt ...... 0.6 

Of this he directs the injection of two syringefuls, carry- 
ing about 18 grains of the quinine. 

Alimentation is of the first consequence in the 
treatment of the reaction period. I have already 
indicated the kind of foods required. Solid foods 
must be avoided until digestion is resumed. Only 
liquid foods, as milk, wine-whey, koumiss, may be 
given at first, and even these must be given up if they 



122 CHOLERA. 

cause vomiting. When digestion is resumed a weak 
animal broth, soft-boiled eggs, sweetbreads simply 
stewed, or raw oysters, are suitable articles of diet. 
A very small quantity of food should be taken at a 
time ; nor should the intervals of feeding be short. 
The ability of the stomach to dispose of food should 
be aided by the administration of pepsin and lactic 
and hydrochloric acids. 

Having now passed in review the various remedies 
that have been proposed in the treatment of cholera, 
I intend giving an account of such plans or methods 
of management as the experience of physicians prac- 
tising in the centres of cholera infection have most 
approved. We have many expressions of opinion 
from the physicians of Hamburg, where cholera has 
assumed its severest form, and of Paris, Berlin, St. 
Petersburg, and other places when it has been less 
severe, although eminently characteristic. Prof. 
Rumpf, of Hamburg, concludes from his observa- 
tions that the most advantageous plan of treating 
cholera consists in the exhibition of calomel — a large 
dose at the outset, about eight grains, and smaller 
doses, one-half grain to two grains, every two, 
three, or four hours ; prolonged hot baths at the 
temperature of 104° F. in the cold stage; intra- 
venous transfusion of salines ; small doses of mor- 
phine hypodermatically for the cramp, and the 
subcutaneous injection of ether and oil of camphor 



TREATMENT. 123 

as cardiac stimulants. During the diarrhoea stage 
Rumpf makes use of Cantani's enteroclysis, but finds 
it of little or no avail afterward, and he no longer 
depends on salol, creolin, and other intestinal anti- 
septics, having seen their inefficiency. He is, also, 
opposed to the use of opium in any considerable 
quantity, especially by the stomach, because it brings 
on a paresis of the intestine and deepens the stupor 
of the algid stage. 

Prof. Cantani, 1 of Naples, has brought into use 
two new expedients for the treatment of cholera — 
enteroclysis and hypodermatoclysis — and has also 
been active in promoting intra-venous infusion of 
salines. He affirms that he invariably cured cholera 
diarrhoea by means of enteroclysis. Many remedies 
will arrest the diarrhoea that are quite powerless in 
the algid stage, and this is not an exception to the 
rule. Cantani assumes that the fluid will always 
pass through the ileo-csecal valve, an assumption not 
warranted by the facts, Daland's experiments having 
shown that in one-third, certainly, the fluid does not 
pass into the small intestine. Cantani also advocates 
his method of hypodermatoclysis as a substitute for 
venous infusion of salines. 

Dujardin-Beaumetz's treatment at the Hopital 
Cochin, Paris, was as follows : Those admitted in the 

1 Berliner klinische Wochenschrift. 



124 CHOLERA. 

algid state were enveloped in blankets and sur- 
rounded by bottles of hot water. Lactic acid was 
administered every quarter of an hour — three table- 
spoonfuls of this mixture given at a dose : 

R. — Lactic acid . 10 grammes = 155 grains. 

Simple syrup 20 " = i oz. (nearly) 

Tinct. of citron 2 " = 3ss. 

Water (steril.) 1000 " =1 quart. 

To arrest the vomiting, bits of ice were swallowed ; 
iced milk and carbonated waters were also allowed. 
Every hour twenty drops of paregoric. Sometimes 
Lausedat's drops were given, as follows : 

R. — Ethereal tincture of valerian . 5 grammes 
Laudanum .... 1 gramme. 

Essence of mint . . .5 drops. 
Hoffman's anodyne . . .5 grammes. — M. 
S. — Twenty-five drops were given for the vomiting and 
diarrhoea. 

Against the cramps, small doses of morphine were 
administered subcutaueously, and against failure of 
the vital powers, injection of ether and caffein were 
employed. Intra- venous infusion of salines according 
to the formula of Hay em was used, as follows : 

R. — Water distilled and steril. 1000 grms. = 1 quart. 
Chloride of sodium . 5 " = 77 grs. 

Sulphate of sodium . 10 " = 155 " 

At the Hopital Cochin, also, they irrigated the 



TREATMENT. 125 

stomach with recently boiled water containing some 
boric acid, according to the method of M. Bourcy. 
The intestines were irrigated by a naphthalized solu- 
tion, twenty centigrammes to one thousand grammes 
iu strength, an oesophageal sound being passed up as 
far as possible to carry the fluid high up iu the 
intestines. 

At the military barracks in Hamburg they em- 
ployed Cantani's tannin enteroclysis, lactic acid, and 
resorcin by the stomach, but especially calomel. 
Both intra-venous infusion and hypodermatoclysis 
were resorted to, the advantage, however, remaining 
with the former. In Paris, Dr. Mathieu gave 
chloroform water, champagne, and sterilized milk, 
and sixty to eighty grammes of talc 1 in wafers, per 
day. Against the cramps he employed injections of 
morphine, and of cocaine, dry friction massage, and 
warm baths. M. Delpech reports excellent results 
from the use of creasote — two to three grammes — by 
irrigation. 

I must not fail to describe the treatment pursued 
at New York quarantine, 2 which, although similar 
to that made use of abroad, had some special features 
of its own. The " suspects " were required to drink 
freely of hydrochloric acid lemonade 1 : 1000, and 

1 Silicate of magnesia. 

2 The American Journal of the Med. Sciences, January, 1893 : Wilcox, 
Epidemic Cholera in New York. 



126 CHOLERA. 

lavage of the stomach was practised with the tanniu 
solution, or with hydrochloric acid 1 : 1000, every 
two hours. The intestines were washed out with a 
two per cent, aqueous solution of tannic acid, half a 
gallon being used at a time at a temperature of 
108.9° F., and repeated every two hours. A rectal 
tube two feet in length was introduced as far as could 
be done, and when there was difficulty in securing 
passage of the fluid through the ileo-csecal valve, 
massage of the abdomen was practised to overcome 
the resistance. At the outset ten grains of calomel 
were given, and this was repeated every hour until 
three doses were taken, or thorough evacuation 
secured. Afterward one-half grain was admin- 
istered every two hours. Stimulants were used as 
required, preferably brandy, and generally adminis- 
istered hypodermatically. When the algid stage 
came on, hypodermatoclysis was resorted to, the 
solution employed consisting of " sodium chloride 
3 parts, brandy 10 parts, to 1000 parts of sterilized 
water kept at a temperature of 104° F. One quart 
was used for an adult, and it was injected into the 
flanks at about the eighth rib, and was repeated 
every second to fifth hour according to the necessities 
of the case. The largest amount used in any one case 
was eleven quarts." 



INDEX. 



Algid stage of cholera, 50 

Alimentation, 121 

Altona, cholera in, 30 

Anticholerine, 115 

Apparatus for intra-venous infusion, 103 

for hypodermatoclysis, 108 
Arabia, cholera in, 22 
Arndt, Prof., 33 

Bacillus of cholera, 35, 36, 37 

experiments with, 42 
Baths in cholera, 118. 119 
Beaujon Hdpital, cholera at, 117 
Blood-serum injections, 88 
Bujwid, Dr., 95 

Caffein, 116, 121 
Cairo, cholera in, 22, 25 
Calomel in cholera, 89, 96, 122 
Cantani, Dr., 97, 123, 125 
Causes of cholera, 21 
Chloral in cholera, 117 
Chlorine gas as a disinfectant, 80 
Chlorodyne, 93 
Cholera in Altona, 30 
in Arabia, 22 



128 INDEX. 

Cholera in Hamburg, 23, 30 

in Havre, 23 

in Kashmir, 25 

in Marseilles, 23 

iu New York, 18 

in Nietleben Asylum, 23, 33 

in Paris, 23 

in Portal, 24 

in Russia, 31 
Cholera sicca, 53 

spirillum, 35 

vaccine, 86 
Cholerine, 13 
Clemow, Dr., 31 
Climate, influence of, 25 
Clothing, disinfection of, 82 
Corrosive sublimate solution, 79 
Course of cholera, 64 
Crocq, Dr., Ill 
Cultures, 36, 70 

Dr. Dunham's, 36 

Daland, Dr., on cholera in New York, 119 
Delpech, Dr., 113 
Diagnosis, 69 
Diarrhceal stage, 45 
Disinfection, 77 

arrangements of German Government for, 81 

of clothing, 77, 78 

of individuals, 79 

of privies, 82 

of rooms, furniture, etc., 82 

the materials for, 77, 79, 80 



INDEX. 129 

Drinking-water as a cause of cholera, 30 
Dujardin-Beaumetz's treatment, 123 
Duke, Dr., on treatment of cholera, 120 
Dunham, Dr., cultures of bacillus, 36, 37 
Duration of cholera, 63 

Elevation, effect of, on epidemics, 25 

Elimination treatment, 88 

Emmerich, Prof., experiment with germs, 42, 65 

Enteroclysis, 97 

Epidemic of 1831, 15 

of 1848, 15 

of 1866, 16 

of 1892, 17 

in New York, 18 
Etiology of cholera, 20 

Galliard, Dr., 110 
Guttmann, Dr., 43 

Haffkine, Dr., vaccine, 86 

Hamburg, cholera in, 30 

Hasserlik, experiment with germs, 35, 65 

Hayem, Prof., 90, 124 

Hope's mixture, 90 

Humidity as a cause of cholera, 25 

Hypodermatoclysis, 109 

Infection stage, 48 
Infections, microbial, 86 
Injection of blood-serum, 87 

Instructions of German Government for disinfection, 81 
Intra-venous saline infusions, 110, 124 
apparatus for, 103 



130 INDEX. 

Iodoform, 95 

Irrigation of the intestine, 97, 123 

Johnson, Dr. George, 88 

Kidneys, state of, in cholera, Gl 

Klebs's anticholerine, 115 

Koch, Prof., discovery of comma bacillus, 34 

propositions regarding germs, 71 
Kohos, Dr., 117 

Lactic acid, 124 
Lauenstein, Dr., 92 
Lavage of the stomach, 113 
Luton, Dr., Ill 

Manchot, Dr., 115 
Mathieu, Dr., 125 
Mecca, cholera in, 22 
Medina, cholera in, 22 
Mendel and Simon, Drs., 91 
Microbial infections, 86 
Morbid anatomy of cholera, 58 
Mortality from cholera, 67 

at Hamburg, 67 

at Havre, 67 

at Kashmir, 68 

at Nanterre, 68 

at Nietleben, 67 

at New York, 67 

in Russia, 68 

Nanterre, cholera at, 23 
Naphthalin, 95 



131 



Nedzwedzki, Dr., 125 
Nietleben Asylum, 23 

Occupation, influence of, 29 
Opium in cholera, 100 

Pathology of cholera, 58 
Pettenkofer, 26, 33, 42, 65 
Pilocarpine in ursemic stage, 120 
Plate cultures, 36, 70 
Portal, cholera at, 23 
Posner, Dr., 43 
Prevention of cholera, 76 
Prodromal stage of cholera, 45 
sis of cholera, 72 



Quarantine at seaports, 76 

on land, 80 
Quinine in cholera, 121 

Reaction stage of cholera, 54 
Reiche, Dr., cholera in Hamburg, 
Rubini's solution of camphor, 92 
Rumpf, treatment of cholera, 122 

Salol in cholera, 94 

Sandwith, Dr., cholera in Arabia, 25 

Bex, influence of, 26 

Shaven-beard appearance, 59 

Siredey, Dr., 118 

Sodium phosphate injections, 111 

Soil, influence of, 26 

Spirillum of cholera, 35, 36, 37 

Sternberg, Dr., 77 



132 INDEX. 

Sulphuric acid in cholera, 89 
Sulphurous acid gas, 89 
Sunlight, action of, on germ. 77 
Surface-water, 26 
Susceptibility, 41 
Symptoms of cholera, 45 
Systemic injection, 48 

Tannic acid in cholera, 91 
Treatment of cholera, 74 
Trussewitsch, Dr., 116 
Typhoid stage, 55 

Uffelmann, Dr., on viability of spirillum, 39, 
Ursemia, 56 

Vaccine of cholera, 86 
Vachovitch, Dr., 89 
Viability of cholera germs, 78 

Waldeck, cholera at, 30 

Warm baths, 118 

Water-supply as a cause of cholera, -!'.* 

Winternitz, Dr., on baths, 118 

Ziemssen, Prof., 99, 100 



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